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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 I YEAR FROM DATE ISSUED <br /> JOB ADDRESS Ci' CITYIZIP / <br /> H <br /> CROSS STREET V1 APN PARCEL SIZE • �tyy <br /> h7 <br /> OWNER NAME 0437 PHONE % / - 175704 <br /> OWNER ADDRESS `11i <br /> ��// {✓ CITY/STATE/ZIP <br /> CONTRACTOR 1 StOCPHONE c2d A �ICf— !SOV <br /> CONTRACTOR ADDRESS CP O n r • CITYISTATE/ZIP W/, <br /> n <br /> LICENSE ❑ -42 11OC-36 OTHER NUMBERO CIRATION DATE <br /> WATER TABLE DEPTH: �� - U �/ ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: LI NEW INSTALLATION REPAIR/ADDITION LJ 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 ��( S�1✓i°1 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 /> �j LEACH LINES x <br /> LEACHING CHAMBERS #OF LINES �Ca LENGTH OF LINES �O ft <br /> / DISTANCE TO NEAREST WELL ft FOUNDATION Z�7 ' 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 CZ WIDTH C9 I , ft LENGTH 141 / ft DEPTH 6' ft <br /> • DISTANCE TO NEAREST WELL r 0 / 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 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 /> MINIMUM `OHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 /Q <br /> SIGNED TITLE Af DATE <br /> Run IEWI <br /> N <br /> Als <br /> a <br /> Q IN <br /> E 0 <br /> H EPARTMENTUAE 9NAY <br /> Application Accepted By Date Area L Employee ID#� <br /> Final Inspection By Z Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PiVS4np Soil Character: <br /> COMMENTS :jy- <br /> PE SC Received Xfi-eckW Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />