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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 9.53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ! /CITY ZlP ^� <br /> CRO55 STREET <br /> APN / 4 �r lPARCEL SIZE 0 �' — <br /> OWNER NAME `^ a7 <br /> lJr�� !— L.�V �� PHONE <br /> IIt�� � <br /> OWNER ADDRESS _ CITYISTATEIZIP _ <br /> qvLCONTRACTOR Lf _ __ PHONE <br /> CONTRACTOR ADDRESS C(oLJ I _�` �� �v( CITY/STATE/ZIP <br /> LICENSE UC42 17C-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 L REPAIR/ADDITION L ENGINEER DESIGNED/ALTERNATIVE <br /> LI REPLACEMENT DESTRUCTION L-- <br /> INSTALLATION WILL SERVE: E RESIDENCE ❑ COMMERCIAL �NOIM�IEROF <br /> �- <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: MPLOYEES: <br /> ❑ SEPTIC TANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑I GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ `LIFT STATION SIZE — TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES E LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It <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 It <br /> ❑ DISPOSAL PONDS WIDTH - ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE To NEAREST W€LL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBYCERTIFY T HAVE PREP ED 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 /> UR ADVANCE NOTICE REQUIRED FOR INSPEC IONS,-/PL,EASE CALL(209)953-7697 <br /> SIGNED TITLE DATE DATE 2 <br /> ti w <br /> � S <br /> T <br /> �1 <br /> T <br /> • DEPARTMENT LIV ONLY <br /> Application Accepted3 Date Area Employee ID#, ���7 <br /> Final Inspection By Cp Date a 26 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to D pth of 3 Ft: PiVSump Soil Cha aeter: <br /> COMMENTS 0 --Lk-El I:3 *4e- dervlwtiSkJ-(4s jk9k- <br /> - P Y1 Ld5+- -f DL.60—L.60— ed 61-1� <br /> r <br /> PE SC Received liec Amount Permit! <br /> Code INFO B sh Remitted Date Service Request# Invoice# Permit ID# <br /> dZ-)L- <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 10!4/07 <br />