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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 ADDRESS ZF, vv E- CITY/ZIP <br /> CROSS STREET vll Jew AP U 6S /! PARCEL SIZE!UT <br /> OWNER NAME �'I (r� 1 PHONE <br /> OWNER ADDRESS O CITYISTATEIZIP <br /> CONTRACTOR (^ u` l/ G PHONE <br /> CONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE #C-42 110C-36 OTHER NUMBER /� SEXPIRATION DATE <br /> WATER TABLE DEPTH: v ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: Ll NEW INSTALLATION U REPAIR/ADDITION LJ ENGINEER DESIGN /ALTERNATIVE <br /> REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: p NUMBER OF BEDROOMS: / 1 NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG L �- CAPACITY / G" V gal #OF COMPARTMENTS c" <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL /O-!S ' 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 C"�^WI bQ�^S #OF LINES _ LENGTH OF LINES SS ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION /00 ft PROPERTY LINE 1S ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ff <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE_0 ° ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH SAAi=! GU1� <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft -- PROPERTY LIN AQU ft <br /> LJ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH LT NSF'VUN�fU <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE RTM�.,Itt <br /> SEEPAGE PITS NUMBER 3 WIDTH ' ft DEPTH 1.2 S' ft <br /> DISTANCE TO NEAREST WELL Sa ft FOUNDATION 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 `OHOUR ADVANCE NOTICE REQUIRED FOR INSPECT ONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE <br /> N <br /> +fE- <br /> S <br /> Y <br /> l l <br /> EN <br /> X <br /> s 14 <br /> SdU4 ah <br /> PARTMENT USE Y <br /> Application Accepted y Date Area Employee ID <br /> � <br /> Final Inspection By /' Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to 6epth of 3 Ft: Pit/S mp Soil Character: <br /> COMMENTS-J' (Z IA Z 66 <br /> a aI vac `t1J yL�_ i vt <br /> PE SC Received Check# Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO ash Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />