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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 EXPI <br /> �R <br /> �E <br /> /S 1 YEAR <br /> FROM DATE ISSUED <br /> JOB ADDRESS ^ Ol{i Y/ZIP ' 4'/-/t/ <br /> :.I <br /> t� <br /> CROSS STREET APN " OZZPARCEL SIZE <br /> OWNER NAME �µS�'- PHON <br /> OWNER ADDRESS O ✓ �✓ WP���I�(J(G �7 CITY/STATE/ZIP <br /> Ci <br /> CONTRACTOR CSl.�il?Z C�-n �L A,�; / PHONE 9(9 / <br /> / <br /> CONTRACTOR ADDRESS 8 S 2S iQ��i - CITY/STATE/ZIP <br /> LICENSE ❑❑C-42 ❑GC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST +L BUILDING PERMIT LAND USE APPLICATION# <br /> TYPE OF WORK: a NEW INSTALLATION EPAIR/ADDITI0N ENGINEER DESI NED/ALT NA VE <br /> .rte_ <br /> REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL ERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: 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 /> I LEACH LINES �LE��� #OF LINES ES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> � <br /> FILTERBE ,L WIDTH I3 / ft LENGTH h'22 ft DEPTH ft <br /> V —�\ ++ 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 /> ❑ 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 /> MINIMU4d U AD NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE <br /> � M <br /> D P <br /> EPARTMENT .�SnE/ Y <br /> Application Accepted B, Date 6 vv Area Employee ID#� <br /> Final Inspection By « Date 45�1 ❑ SPE IAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> ef <br /> PE Sc Received heck# Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO /,BY Remitted S rvice Re uest# <br /> 60SS3 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4124/12 <br />