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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1368 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 CITY/LZIJ]P� T� J <br /> CROSS STREET N//TQC r �/K/ � l�� APN 06'e ` D l PARCEL SIZE L <br /> OWNER NAME PHONE <br /> OWNER ADDRESS L CITY/STATEIZIP <br /> CONTRACTOR ceo l V10 C PHONE 4;�0 r <br /> CONTRACTOR ADDRESS Oki 4)ee, CITY/STATEIZIP W/�y�/ <br /> LICENSE 11)(C-42 ❑❑C-3 �� <br /> 6 OTHER NUMBER 0 SEXPIRATION DATE <br /> WATER TABLE DEPTH' o ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: LI NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: C / 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 ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS Io ��wll 's #OF LINES//,^ LENGTH OF LINES Z/0 ft <br /> DISTANCE TO NEAREST WELL�C20 ft FOUNDATION (.CSO 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 3 WIDTH — ft DEPTH o25- ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ZOel ft PROPERTY LINE �O 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 j2HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-P//LEASE CALL 209 953-76977 <br /> SIGNEDTITLE CAiI/�'Csl1�/ DATE <br /> tj <br /> Q <br /> ti <br /> JEPARTMENTIUSE ONLY <br /> Application Accepted y Date Area Employee ID# <br /> Final Inspection By Date 5 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil <br /> ltto,Depth of 3 t: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Receivedheck Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />