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. r <br /> 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 <br /> 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS / Jy�` C � ��/J /V4,) r rcjc CITY/ZIP <br /> y <br /> /� In <br /> CROSS STREET Coecle-- APN D6q- ,`�✓ 4) PARCEL SIZE d <br /> OWNER NAME =' �// �C`,� lt� '�P� •h t_ PHONE� J <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR �����- *�`� icy PHONE y� co �V��j✓�ZJ r <br /> CONTRACTOR ADDRESS [J� J (��/�.�}LJ v G f CITY/STATE/ZIP <br /> i <br /> LICENSE ❑0C-42 ❑0C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATIOCoor inates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# i AND USE APPLICATION# <br /> TYPE OF WORK: U NEW INSTALLATION U RE AIRIADDITION U ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> L 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 ❑ PK G TX P NT ❑ SAND OV,SEPARATOR(ENCLOSED SYSTEM) <br /> f <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 �I ft LENGTH b O r ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE t Go' 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 LAND RU ND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMU 114 E CE RE MIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED / TITLE DATE <br /> r <br /> A. <br /> 0 <br /> U <br /> T <br /> DEPARTMENT USE LY <br /> Application Accept4By Date a If Area Employee ID# _ <br /> Final Inspection By Date D ❑ SPEC AL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS �}'�oyG-b /> / �'�G,� Sr-dDZ! G/ <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Re uest# <br /> 42-01cjs3SOle�G ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 O o <br />