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t , <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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 111-36 C ti.S'} St F / 14� CITY/ZIP L ("Kf-FVP. D c7S 37 y <br /> CROSS STREET ) Ve APN �0- PARCEL SIZE tz <br /> t <br /> / ^ QQ C r <br /> OWNER NAME 1-19 C �SorJ l I1� � C�W�1 r PHONE� (���� �D�'"�✓C� v� <br /> n l <br /> OWNER ADDRESS t1'L S f CITY/STATE/ZIP too oc <br /> CONTRACTOR (�W,lee e le PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 110C-42 ❑❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: J ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# I LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION LJ REPAIR/ADDITION LJ 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: 3 NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG i �C CAPACITY . gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG 1­6� CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL V 0 -" ft FOUNDATION V ft PROPERTY LINE <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES 1 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 10 ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 /> a SEEPAGE PITS NUMBER '7 WIDTH :h ft DEPTH a,r/ p ft <br /> DISTANCE TO NEAREST WELLk_ ft FOUNDATION D 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 /> I 0HO ADVANCE NOTICE REQUIRED FOR INSPECT.I/ON/S�-PLEASE CALL 209 953- 697 <br /> SIGNE �"� TITLE 1✓/v /L DATE O <br /> El <br /> N 0 <br /> IEW <br /> CA <br /> R T <br /> _ DEPARTMENT USE ON Y <br /> Application Accepted By ate J '"I Area Employee ID# <br /> Final Inspection By Ak v Date 2 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO fly w C4.11 Remitted Service Request# <br /> 1 f S$ fo-1-t <br /> 42-01 p ) I ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />