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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 /> NOWREFUNDABLEnnPERMIT r' CALF 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS d. �3 1 C L CITY/ZIP 6'q(T <br /> CROSS STREET APN / V -l / v - . v PARCEL SIZE � H> <br /> d <br /> -7 �d�f <br /> OWNER NAME Z ri PHONE v� <br /> OWNER ADDRESS Zi'; , 4\ I Z- Al, e 'Pr--ec LG-:C CITY/STATE/ZIP q <br /> CONTRACTOR C����1 V\1h ` s�P�^�'` \ PHONE (' 1 ]U C� } <br /> CONTRACTOR ADDRESS ✓ �`4 pv (� CITY/STATEIZIP TU(�(',•C 1( <br /> LICENSE ❑11C-42 1113C-36 OTHER NUMBER �)3 1 EXPIRATION DATE <br /> 1 ' <br /> WATER TABLE DEPTH: I U� ft GEOGRAPHICAL INFORMATI Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION LI REPAIR/ADDITION Li ENGINEER DESIGNED/ALTERNATIVE <br /> 0 REPLACEME T 0 OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> JJ NUMBER OF LIVING UNITS: t� NUMBER OF BEDROOMS: mm /� NUMBER OF EMPLOYEES: <br /> b1 SEPTIC TANK TYPE/MFG Y CAPACITY V `' gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ' ft FOUNDATION ft PROPERTY LINE f ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT L3 SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> ti 1 <br /> DISTANCE TO NEAREST WELL. 1-QL] ft FOUNDATION -f- ft PROPERTY LINE l 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 WIDTH -2" ft DEPTH v' I ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE :3 S 'I 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 Y3 HOUR A®OANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697`/ <br /> SIGNED TITLEDATE 'S <br /> UA <br /> 44 <br /> I 16 <br /> _ A <br /> N <br /> T A <br /> L <br /> ARTMENT SE N <br /> Application Accepted By Date Area Employee ID# l/ <br /> Final Inspection By lC;l n f Lt i Date IDA liq ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to D th of 3 Ft: Pitl ump Soil Character: <br /> COMMENTS <br /> PE SC Received Checic#/ Amount Permit/ <br /> Code INFO By as emit d Date Service Request# Invoice# Permit ID# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />