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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 YEA FROM D TE,ISSUED <br /> JOB ADDRESS <br /> - L InAlo CITY/ IP S� <br /> { I��{�c1I� �►f�C1VE��/ � —I / PARCEL SIZE <br /> CROSS STREET APN O <br /> d <br /> OWNERNAME 2— PH l-I 7q-0 <br /> -O 65 7 <br /> L &CITY/STATE/ZIP OWNERADDRESS m <br /> ✓ ��� <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑❑C-42 ❑❑C-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: u NEW INSTALLATION U REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM )el 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 ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> An T <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE *E <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH lV ft- <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH �� 8 7nipft <br /> ( <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY Ll M JOQn ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH NVI�VlrAl-t <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE EPART�.�.._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 /> tINIM '8 HOUR A NOTICE RE UIRED FOR INS ECTIONS-PLEASE CALL 209 953-7697SIGNETITLE jqG715AA DATE <br /> PARTMENT USE N Y <br /> Application Accepted By Date Area Employee ID#, <br /> Final Inspection By Date � � ❑ SPEC AL PERMIT-Approved by <br /> Character of Soil to Deptof 3 Ft: ittsur4n Soil Character: <br /> COMMENTS <br /> o.— <br /> PE SC Received Check#/ Amount DPermit/ Invoice# Permit ID# <br /> Code INFO Cash emi a ate Service Request# <br /> Vi ogn"Aa <br /> ! //�� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 42-01 * <br /> 4/24/12 <br />