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5w^ 1-30-17 O�n <br /> 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 PER T L5 <br /> �CAALL /209) 953-7697 FOR INSPECTIONS EXPIRES 1 YE R FROM DAT ISSUED <br /> JOB ADDRESS J/ ---t l �J C'►Ol/Y/L^Z/IP <br /> CROSS STREET �O �Cr""' APNT / ' - �l V PARCEL SIZE� � b <br /> o <br /> OWNER NAME v � PHONE <br /> OWNER ADDRESS��4q, ALAe� CITY/STATE/ZIP 7 � f/J� <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE ❑CIC-42 ❑DC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ENGINEER DESI ED/ALTS ATIV <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION L <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL EllOTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASETRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE it <br /> ❑ LIFTSTATION SIZE TYPE OF PUMP ❑ PKGTXPLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS #OFLINEs LENGTH OFLINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH It LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH It LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH it <br /> DISTANCE TO NEAREST WELL It FOUNDATION it PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH it DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> 1 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 9 3-769 <br /> SIGNED a IgAsU -/J A a ei TITLE VOA DATE O t <br /> IT 481 2Lj I <br /> R <br /> DEPARTMENT SE IQ NLY <br /> Application Accepted Date b Area Employee ID#y�'1—� <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received heck#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Remitted Service Request# <br /> cil S A14-A 11VLI Soo cn 5 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />