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ONSITE WASTEWATER TREATMENTPERMIT <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/ZIP U <br /> H <br /> p7 <br /> APN � O10 ' PARCEL SIZE STREET W <br /> OWNERNAME L41e <br /> k)rzaw e-Vt PHONE N <br /> OWNER ADDRESS )� / CITY/STATE/ZIP <br /> CONTRACTOR L�1n1 1�jLY�C_ 1 !���� /(L PHONE <br /> CONTRACTOR ADDRESS O/SC1�� p!Z CITY/STATEIZIP Z�11-z—r <br /> LICENSE 01 2 110C-36 OTHER NUMBERy�6�yS EXPIRATION DATE 65 /`l <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 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 ( w 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 �O ft <br /> DISTANCE TO NEAREST WELL /00 ft FOUNDATION 37 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 /> (d— SEEPAGE PITS NUMBER 9 WIDTH 3 ft DEPTH S' ft <br /> DISTANCE TO NEAREST WELL /SO ft FOUNDATION GAO ft PROPERTY LINE /S 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 REQUIRE®FOR INSPECTIONS- PLEASE CALL (209)953-7697 <br /> SIGNED TITLE /_�N�l9�rC DATE <br /> Sb " �® <br /> s 18 <br /> q <br /> 4T t <br /> R <br /> IR T <br /> p c s <br /> F�F--- <br /> )EQt.E CKN L Y <br /> Application Accepted By Date Area Employee ID#� <br /> Final Inspection BL D C �� ❑ SPECIA�T-Approved b <br /> a sN y b ate rr v <br /> Character of Soil to Dep of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received CheaW Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B a Remitted Service Re u'St# <br /> I `?c <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />