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Jf . 54th 6 0�'-\ P✓ <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 PERMIT CAL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I r`' ')tucwn CITY/ZIP 1 <br /> CROSS STREET APN 1 PARCEL SIZE <br /> OWNER NAME E V w rit C rI oL, PHON .101) [T I/-0-7 2—0 R <br /> OWNER ADDRESS l Q� CITY/STATE21P <br /> CONTRACTOR �� PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑.!C-42 ❑I 'C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESI NED/ALTERNAJAVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION- <br /> INSTAL ATION <br /> ESTRUCTIONINSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS #� rS �� elft N`` ft <br /> DISTANCE TO NEAREST WELL ft F U ATIONLINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH Permit may h fex0re4gAtheut ft <br /> DISTANCE TO NEAREST WELL f�1f ' In,�P„E1f� XjLIN ft <br /> ❑ MOUNDED WIDTH ft LENGTH (J�� 11�'ff"nn } EPT��NN�t/UJ`GG���y11l �.j� ft <br /> DISTANCE TO NEAREST WELL ft viifionmep•8 Hea! UIVASP-41Y LINE�� " ft <br /> ElSUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL_ ft FOUNDATION ft PROP TY LINE ft <br /> ElDISPOSAL PONDS WIDTH ft LENGTH ft DEPTH AN9AQU1 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROP MEN' T- ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-769 <br /> SIGNED TITLE w DATE <br /> IV I <br /> DEPARTMENT IJ SE b NL <br /> Application Accepted Date Area Employee ID# <br /> Final Inspection By Date El SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTSy(� <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Re uest# <br /> ,z7 12 ' <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />