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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 /> KION-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS AJ 0 CITYIZIP_ a'-'– ;Lo-s y <br /> CROSS STREET APN 0311 (� PARCEL SIZE > <br /> iiiTTT �j / ydyyy <br /> OWNER NAME A4 PHONE 4�,/��� /71 <br /> /`/ C. <br /> OWNER ADDRESS >' 1 Lce/ <br /> 61 1^ /Y i1k I �//��J� L F�J��f CITY/STATE/ <br /> -Z <br /> �IP <br /> CONTRACTOR V111 I � L_71 1 `Yr�k��— � 1 I� PHONE OBJ-! �Oy�S 5� <br /> CONTRACTOR ADDRESS A"D,G -1 C I..LJ/4 / G `/1 CITY/STATE/ZIP <br /> LICENSE ❑OC 42 ❑OC-36 OTHER � NUMBER 0c O� EXPIRATION DATE /C-' --3I �� <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: U NEW INSTALLATIONW,--REPAIR/ADDITION LI 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 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 O PKG TX PLANT Q SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> --LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES �� ft <br /> DISTANCE TO NEAREST WELL r FOUNDCA i®N ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTHU�I� vJ�l' 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 L j ft DEPTH 1 ft <br /> / <br /> DISTANCE TO NEAREST WELL l d ft FAUN ATIION ft -- PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH 5D TO QwaIIcft 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 /> MU q3HOAIR A NOTICE REQUIRED FOR INSPECTIONS-PL ASE <br /> CALL a 09 953-7697 <br /> SIGNED <br /> ,f? <br /> �J <br /> 11 L <br /> ly <br /> i < <br /> �. <br /> S <br /> otw <br /> EPARTMENT USE N Y EINVIR, f TY <br /> Application Accepted By Date Area Emplo ee'IliEF E <br /> Final Inspection By Date ! ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received C Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remitted Service Request# <br /> 21 0 111) ov 3�d ltd ��30 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />