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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 I YEAR FROM DATE ISSUED <br /> JOB ADDRESS 0 /' CITYIZIP `�/✓W���^f % S� <br /> CROSS STREET totf/{ n j �G APN �) / yy PARCEL SIZE <br /> d <br /> OWNER NAME e err �PHO/N�E (} M <br /> OWNER ADDRESS v d CITY/STATE/ZIP <br /> CONTRACTOR �AO/�,t9 �. IG �JYLL PHONE <br /> CONTRACTOR ADDRESS ESS / L/ CITY/STATE/ZIP <br /> LICENSE ❑❑C-42 ❑❑ ^ <br /> C-36 OTHER , 1 NUMBER-7/�- /,!9-3 EXPIRATION DATE <br /> WATER TABLE DEPTH/O �L/ ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION e REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: P' RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: l NUMBER OF BEDROOMS: 2 NUMBER OF EMPLOYEES: �f <br /> SEPTIC TANK TYPE/MFGPIIV CAPACITY gal #OF COMPARTMENTS !� <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL '101)1ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES 4 LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft!/!/FOUNDATION ft PROPERTY LINE ft <br /> .ISI FILTER BED WIDTH /0 ft LENGTH C- 1ift DEPTH _ft <br /> DISTANCE TO NEAREST WELL 10,r r ft FOUNDATION /C ft PROPERTY LINE /1!`ie�Z /ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 /> jQ STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM QQ OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 9953-7697 <br /> SIGNED TITLE DATE <br /> JOA <br /> T <br /> J <br /> RAIA <br /> P A <br /> T <br /> PARTMENT UAE O L <br /> Application Accepted By Date Area Employee ID#� <br /> Final Inspection By ci�Ql Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/sump oil Character: <br /> COMMENTS <br /> PE SC Received Check#L..... Amount Date Permitt Invoice# Permit ID# <br /> Code INFOBy Cash Remitted Service Request# <br /> or 12� <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br /> 1r <br />