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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 <br />CALL <br />209 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUE <br />JOB ADDRESS -7� -'N%, <br />(�Q h <br />CITY/ZIP 1 <br />y C A <br />^ <br />CROSS STREET G\� iti-c� �"S-2. 14 �>—)Q <br />I <br />APN 2- 5'0 ` l <br />PAR L SIZE • c!' �CR' <br />OWNER NAMEii ` sS4 <br />✓ <br />SIZE TYPE OF PUMP <br />/4 <br />PHON �' V <br />OWNER ADDRESS \ <br />CITY/STATE/ZIP <br />Q <br />U - <br />CONTRACTOR L— Co <br />e <br />0-- N <br />PHONE p �2 d \ I l `rte -0 <br />CONTRACTOR ADDRESS <br />y <br />L� C'�tT��I$LLF(�,i� CITY/STATE/ZIP:: <br />,AVd C/,2 �f J?l <br />LICENSE ❑❑C-42 ❑❑C-36 <br />OTHER P, <br />NUMBER ��l rI EXPIRATION DATE <br />k, - .3, - <br />WATER TABLE DEPTH: ►-L,— ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # I BUILDING PERMIT # It <br />LAND USE APPLICATION # <br />TYPE OF WORK: `�t- NEW INSTALLATION U REPAIR/ADDITION u ENGINEER DESIGNED /ALTERNATIVE <br />❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE �< COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />D <br />lid SEPTIC TANK <br />TYPE/MFG K�'-Acjel � <br />CAPACITY 12-00 gal <br /># OF COMPARTMENTS Z <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY gal <br /># OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL v -4 y <br />ft FOUNDATION I (3 ft <br />PROPERTY LINE I Ct ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL <br />SEPARATOR (ENCLOSED SYSTEM) <br />0 LEACH LINES <br />❑ LEACHING CHAMBERS _'2) # OF LINES <br />LENGTH OF LINES <br />Check#/ Amount Date <br />Cash Remitted <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />�� <br />FILTER BED <br />WIDTH /0 ft LENGTH O <br />!�i( <br />ft DEPTH 4 ^ <br />� 2 �I <br />ft <br />DISTANCE TO NEAREST WELL !j O C7 ft FOUNDATION <br />ft PROPERTY LINE <br />j40 <br />ft <br />❑ MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SUMPS <br />WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft -- PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) <br />953-7697 <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTSr � t��1�ftf <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Check#/ Amount Date <br />Cash Remitted <br />Permit/ Invoice # Permit ID# <br />Service Request # <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />r <br />