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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 GALL 209 953-7697 FOR INSPECTIONS EXPIRES 1�aY,EEAR FROM DATE ISSUEI <br />Li 6 <br />JOB ADDRESS + Y ^ 1�-C/ CITYIZIP f 1 •I�Lt+.rT 1 �'T J S 77 <br />CROSS STREET APN ?Z OZ6 <br />11 2i0 PARCEL SIZE <br />OWNER NAME I U �e ice' rht• �1 . vY,� � !~-f -v Lit r'), V� l `) PHONE (g 4i( L 0 <br />OWNER ADDRESS Cho'" CITY/STATE/ZIP <br />CONTRACTOR^����i��� ti PHONE_^=5� <br />CONTRACTOR ADDRESS (Ta A-�)w CITY/STATE/ZIP i'► 1!_'i1�Q/_ <br />LICENSE ❑ I C-42 Ell IC -36 OTHER NUMBER 6azGwEXPIRATION DATE/ X <br />i <br />WATER TABLE DEPTH: "V I0 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: I NEW INSTALLATION rR'GPfiIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COM MERCIA, ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal <br /># OF COMPARTMENTS__ <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal <br /># OF COMPARTMENTS <br />DISTANCE TO NEAREST <br />DISTANCE TO NEAREST: WELL Onk ; <br />ft FOUNDATION � _ <br />ft <br />PROPERTY LINE Sr ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />a/<E_ACH LINES I LEACHING CHAMBERS # OF LINES LENGTH OF LINES I +Z1 T ft <br />DISTANCE TO NEAREST WELL r �5� ft FOUNDATION ft PROPERTY LINE �� I ft <br />❑ FILTER BED WIDTH <br />ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION ft PROPERTY LINE It <br />❑ MOUNDED WIDTH <br />ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS WIDTH <br />ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ SEEPAGE PITS NUMBER <br />WIDTH ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION ft PROPERTY LINE 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 HOURAWANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED <br />TITLES ��^e �rz1 DATE <br />Application Accepted B[ <br />Final Inspection By <br />� <br />Character of Soil to Depth of 3 Ft: <br />COMMENTS <br />Date <br />Date <br />Area Employee ID <br />C1 SPECIAL PERMIT - Approved by <br />Pit/Sump Soil Character: <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />eck#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Request # <br />Invoice # <br />Permit ID# <br />O <br />�JService <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />