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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 CAL 9 953-7697 FOR INSPECTIONS r EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS C�00 W CITY/ZIP T <br /> CROSS STREET fS iv.I ck APN �!w / PARC CfSIZE —Oki <br /> �f 7a d <br /> /Yl��{ O PHO ! / <br /> OWNER NAME /�'r� <br /> OWNER ADDRESS V `tiITY/STATE/ZIP <br /> t la, <br /> CONTRACTOR '7 �on!1 CI c lie)r--S �/ /'!{PHONE CQ09 ) 9�7 q <br /> Po 1n <br /> CONTRACTOR ADDRESS o i3i3(-% I' ! CITY/STATE/ZIP oy�{/�t�Sj/ A <br /> LICENSE 1111C-42 �' C-36 OTHER NUMBER XPIRATION DATE— <br /> WATER <br /> ATE—WATER TABLE DEPTH: U ft GEOGRAPHICAL INFORMom—ATI CO dl tes X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: L NEW INSTALLATION LI R PAIR/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: NUMBER OF EMPLOYEES: <br /> ❑/SEPTIC TANK TYPE/MFG J -v CAPACITY gal #OF COMPARTMENTS <br /> Q GREASE TRAP TYPE/MFG j Q(I S01V CAPACITY gal #OF COMPARTMENTS_ <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION /[f' / ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANND SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATIbN 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 fl 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 /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MMVIMUIW 0 HOUR CE NOTICE REQUIRED FOR IN P CTIONS -PLEASE CALL 209 53-7697 <br /> SIGNED TIT L &� DATE G / <br /> N� <br /> R <br /> N <br /> D`E ARTMENT U E N Y <br /> Application Accepted / Date40 <br /> t Area Employee ID# <br /> Final Inspection ByiAt -eG�i+1 �r � Date [��/ ��� ❑ SPECIAL P RMIT-Approved by <br /> w�� <br /> Character of Soil to Depth of 3 Ft: PiVSump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> ode INFO B ash Re 'to Date Service Request <br /> # Invoice# Permit ID# <br /> 42-01 �Jr�� ' ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 U <br />