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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 CAL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP S� c A."• �%�, 9 <br /> H <br /> c _ 7/ � <br /> CROSS STREET S,�tib' �l' APN Z '7 - J 4' J PARCEL SIZE �-� �- d <br /> OWNER NAME <br /> •'L r �j=S Gc� I PHONE -2V% �/✓ �Z / v� <br /> OWNER ADDRESS / / -3 Z� ✓ �r CIN //STATE/ZIP �Sf_/3/�°U C.Z4 /Cs 77c� � <br /> CONTRACTOR / ^��sJr rte'-7�� �="�r�l �� PHONE ' <br /> CONTRACTOR ADDRESS / �- r'? / CITY/STATE/ZIP <br /> LICENSE 110C-42110C-36 OTHER NUMBER 5L5Z7/> EXPIRATION DATE �=-- 0/ <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 a REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERN IVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION `J f <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG 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 0 SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 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 /> ❑ 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 /> MINIMOk HOUR DI IV CE N TI E REQUIRED FOR iNSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE <br /> J <br /> Qak <br /> r <br /> S <br /> N <br /> C F N <br /> R tij <br /> PARTMENT S N Y <br /> Application Accepted"� Date Area Employee ID# <br /> Final Inspection By Date 7,v ❑ SPECTL PERMIT-Approved by <br /> Character of Soil Depth of 3 Ft Pi Sump Soil Character: <br /> COMMENTS <br /> 'wK a-'Move- o✓1 C de f7c to V-e 1- -C I CIA Ot oX I -kr A0,fE 1 <br /> PE SC Received eek Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By_ Remitted Service Re uest# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4124/12 <br />