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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 ADDRESS11:11bbCITY/ZIP �U / <br /> H <br /> C � <br /> CROSS STREET G APN 5 Q �� PARCELSIZE��� O <br /> OWNER NAME V 1 PHONE <br /> r <br /> OWNER ADDRESS f / CITY/STATEIZIP <br /> CONTRACTOR r-1/ V !/�� 'Sw4 C PHONE ..; --I r 2&' 5�—0 0� <br /> CONTRACTOR ADDRESS A3 i ` o, �j CITY/STATEIZIP <br /> LICENSE 11)(C-42 ❑❑C-36 OTHER NUMBER � /e S EXPIRATION DATE <br /> f <br /> WATER TABLE DEPTH: O o ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# U LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION U REPAIR/ADDITION U ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: A.RESIDENC Mo ,� — ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> xSEPTIC TANK TYPE/MFG U� ��' CAPACITY � gal #OF COMPARTMENTS c <br /> GREASE TRAP TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <br /> DISTANCE TO NEAREST: WELL /00 ' + . /ft FOUNDATION /0 ' ft PROPERTY LINE 'n2c) ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 1001, <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES _ LENGTH OF LINES <br /> DISTANCE TO NEAREST WELL SCT ft FOUNDATION /O ft PROPERTY LINE .30 ' 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 fl 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 FOUNDATI N PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER WIDTHEPTH e� ft <br /> DISTANCE TO NEAREST WELL / ft FOUNDATION 00 ft PROPERTY LINE 30 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 q3HOUR ADVANCE NDTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE C l �' DATE //—,;;77 <br /> L <br /> I <br /> r Irl LA <br /> i <br /> HEALrH DEAT E T <br /> e: <br /> t <br /> DEPARTMENT SE 0XLY <br /> Application Accepted By Date Area Employee ID# <br /> Final Inspection By Date 7 Z ❑ SPE IAL PERMIT-Approved by <br /> Character of Soil to Dept of 3 Ft: it/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By j PjstL Remitted Service Re uest# <br /> tIt II 2 S 7 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />