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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 RMIT CALL 209 951-769Z FOR INSPECTIONS EXPIRES 1 YEAR FROM DA.TOSSUED <br /> JOB ADDRESS 2 CITY/ZIP 4 <br /> ` m <br /> CROSS STREET 2' AP N `�jZ, 1 Z-0 <br /> J PARCEL SIZE <br /> OWNER NAME t/ l �4. - �/ PHONE <br /> OWNER ADDRESS � CITY/STATE/ZIPdt <br /> CONTRACTORfAa:&� l/ k-^> `�Z. o`c( �Z7bUv 1' <br /> C . PHONE S �� �Z �T�A <br /> CONTRACTOR ADDRESS W ^moi "� `' CITY/STATE/ZIP 0"- � _ ck <br /> LICENSE ❑❑C-42 1111C-36 OTHER <br /> -2- ( NUMBER 71 EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: U NEW INSTALLATION U REPAIR/ADDITION U GINEER DESIGNED/ALTERNATIV <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM RUCTION <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 ❑ 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 JOA ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPE )�ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH • ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPOVY NE ft <br /> L3 DISPOSAL PONDS WIDTH ft LENGTH ft DEPT `�C•/ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PI IE ft <br /> El SEEPAGE PITS NUMBER WIDTH ft DEP /ROU C "'Y ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPER �_T�/ ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUN RDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MI IMUM q8 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 953-7697 <br /> SIGNED TITL � <br /> Vill <br /> EPARTMENTUSE 95&LY <br /> Application Accepted B Date jY Area Employee ID# <br /> Final Inspection By Date ❑ SPE AL PERMIT-Approved by <br /> Character of Soil to epth of 3 Ft: Pi ump Soil Chara`�er: <br /> COMMENTS�,'�(`I dCSil'O� CA -C)n �Ylfi VLI� �f1C�ts�t0� 1 <br /> PE Sc Received Amount Permit/ <br /> Code INFO B s emitted Date Service Request# Invoice# Permit ID# <br /> 2z I 2 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />