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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 11 YEAR FROM DATE ISSUED <br /> JOB ADORESS' .• _ I=S�..oy��n . iuC:.l7d"/ZIP <br /> CROSS STREET n 7 �Jp APN ` �`1 t I j PARCEL SIZE p?" p <br /> OWNER NAME /D2�yGli. PHONE(-.�O�f� <br /> OWNER ADDRESS 17(Peu /i/ZQ�Z�tQ"L� Ci-e�-4L77 CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE L.]C-42 [JC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION _ ENGINEER DESIGNED/ALTERNATIVE <br /> G REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM _ DESTRUCTION S�`<`?rtiP_ �a* '��-- <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE '❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <br /> ❑ GREASETRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCETO NEAREST: WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES J LEACHING CHAMBERS #OF LINES LENGTH OF LINES it <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCETO NEAREST WELL It FOUNDATION ft PROPERTY LINE It <br /> ❑ MOUNDED WIDTH ft LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It <br /> ❑ SUMPS WIDTH It LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSALPONDS WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTYLINE It <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MIM/ UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED el' O/ TITLE OW-n�t DATE <br /> p <br /> T 1R <br /> r <br /> S <br /> I"} DEPARTMENTIAS O LY _ <br /> Application Accepted By 'd L/U'�CrL"""" Date 1' �' Area �°' Employee lD# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS JO 'T >tr' <br /> clv1 {--sl..4- �pp 1:1--1r.(z-I i b <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO By Cash Remitted Date Service Request# Invoice# Permit ID# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />