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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 CALF 209 953-7697 FOR INSPECTIONS ..// EXPIRES 9 YEAR FROM DATE OSSUED <br /> JOB ADDRESS i &Q TOiI <br /> CITY/ZIP S /OC J <br /> Q <br /> CROSS STREET AP�NJ/Z% 0 S-a6 PARCEL SIZE 7 �G <br /> OWNER NAME 166 4-/� T/O//�V /.'s Ti�iG T ` PHONE ff7 v� <br /> OWNER ADDRESS _37.3 �i %A//1J S TiZE.y�T CITYISTATE/ZIP � <br /> CONTRACTOR I1 / PHONE ,-7.01?— <br /> CONTRACTOR ADDRESS i4OM5 A I&lr CITYISTATEIZIP /O G TyN 9SZI_� <br /> LICENSE 110C-42 ❑❑C-36 OTHER G �Z/ NUMBER 7 ZY EXPIRATION DATE <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 U REPAIR/ADDITION U � GINEER D /ALTERNATIVE <br /> ❑ REPLACEMENT El OUT-OF-SERVICE SEPTIC SYSTEM � DESTRUCTI <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 /> d 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 /> U 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 /> MINI!!l1 `{8 R -RE DIRE®FOR INSPE TIONS-PL,--ASE CALL 209 953-N97 <br /> SIGNED TITLE <br /> or <br /> E <br /> - DEPARTMENT USEONLY- <br /> Application Accepted By Date Area Employee ID#� <br /> Final Inspection By Date ❑ SPE AL PERMIT-Approved by <br /> Character of Soil to Depb J3 Ft: Pit/SuI p oil Characte . <br /> COMMENTS -� W ekA <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> ZZI /9 iq <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />