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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 �1�enCALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FP <br /> OM DATE ISSUED <br /> JOB ADDRESS D C '' <br /> I �( (D �Ll�� d-e-r //�J CITY/ LA <br /> �ZIP ��Q �/ <br /> CROSS STREET 0_0AJ/� APN_�/�_10 • (2— PARCEL SIZE p <br /> cin M <br /> OWNER NAME PHONE 73(�'�+ <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR M1 t-C �LYC��� _ PHONE " " <br /> CONTRACTOR ADDRESS p ��,� 5':� CITY/STATE/ZIP pft.40/ i� f�i�► <br /> LICENSE I C-42 C-36 OTHER L�- NUMBER EXPIRATION DATE <br /> r <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> F1 PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT _I OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: LI*SIDENCE ❑ COMMERCIAL _I OTHER <br /> NUMBER OF LIVING UNITS: j NUMBER OF BEDROOMS: V 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 /> Dl-LEACH LINES LEACHING CHAMBERS / y #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ( "315 J ft FOUNDATION 3S 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 /> Q SEEPAGE PITS NUMBER :)L WIDTH ��f( ft DEPTH � S i ft <br /> � <br /> DISTANCE TO NEAREST WELL LSO ft FOUNDATION ft PROPERTY LINE j ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 H VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE )3 <br /> 1 l <br /> EPARTMENT SE Y <br /> Application Accepted By Date Area Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pi ump Soil Character: <br /> COMMENTS rff" <br /> PAYMENT <br /> PE Sc Received Check Amount Permit/ KE <br /> Code INFO B sh emitted Date S rvi R uest# Invoice# ermlt ID# <br /> uu La5 2U <br /> SAN j 401 IIN N <br /> ENVIRONMENTAL <br /> 2-01 ONSITE WASTE <br /> 42-01 <br /> 4WLFR `W9 PERMIT <br />