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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 EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIPcl U <br /> 911, <br /> J 2 7 �,Q�� <br /> CROSS STREET W�� /� APN O�/ - !� '�� PARCEL SIZEx^/ ,� <br /> OWNER NAME M 1 PHONE <br /> f � <br /> OWNER ADDRESS /A ` CITYISTATE/ZIP <br /> CONTRACTOR /Ci/v PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑11C-42 ❑❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: "/(/ ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # F BUILDING PERMIT# UkD1 LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION L1 R PAIR/ADDITION LJ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEME ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: y}(� NUMBER OF EMPLOYEES: /f <br /> SEPTIC TANK TYPE/MFG CAPACITY /TJ gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG y CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL U 1 ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ 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 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 /> SEEPAGE PITS NUMBER �i WIDTH able ft DEPTH ,z I 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 /> MINIMUM HOUR ADVANCE NOTICE REQUIRED FOR INS ECT/ONS- PLEASE CALL 209 953-7697 <br /> SIGNED — TITLE DATE <br /> � N <br /> / (J <br /> 0 F <br /> T <br /> -0 ARTME U E ONXY <br /> Application Accepted By Date Area Employee ID#-- <br /> Final Inspection By t ti Date 1 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received he Amount Permit/ <br /> Code INFO B Cash emi ed Date Service Request# Invoice# Permit ID# <br /> W uT <br /> 5 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />