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n <br /> 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 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ( V' r. CITYIZIP S ✓I y <br /> CROSS STREET j• a APN / PARCEL SIZE C <br /> yd <br /> OWNER NAME NArOPHONE <br /> OWNER ADDRESS /_, '�/ CITY/STATEIZIP ,q /�/� C <br /> CONTRACTOR tv I V/ 1I ,C PHONE p� I X4p g _/.70a T17�/ ./n <br /> CONTRACTOR ADDRESS J SON �� . CITY/STATEIZIP ! <br /> LICENSE 11�C-42 ❑0C-36 OTHER NUMBER S EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATIO Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# . LAND USE APPLICATION# <br /> TYPE OF WORK: U NEW INSTALLATION R PAIRIADDITION U ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: //�� ❑ RESIDENCE 11 COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: .-L. NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG >L D'�,aj7'34j 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 EIPKG TX PLANT ElSAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> xLEACH LINES ❑ LEACHING CHAMBERS #of LINES LENGTH OF LINES 55 ft <br /> DISTANCE TO NEAREST WELL /30ft FOUNDATION -PO ft PROPERTY LINE 6-0 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 � a It <br /> ft DEPTH �5 ' ft <br /> DISTANCE TO NEAREST WELL /.30 , ft FOUNDATION Ute+ ' 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 /> MINIMUM 40 ADVANCEWOT/CE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-71697 <br /> SIGNED TITLE O 1- DATE Lf—! <br /> f <br /> S . <br /> 3 <br /> I O <br /> DEPAR TMEN S LY <br /> Application Accepted Date Area Employee ID# <br /> Final Inspection By DateM25 SPE L P MIT-Approved by <br /> Character of Soil to Vpthf 3 Ft: Pit/ mp Soil aracter: <br /> COMMENTS z <br /> a <br /> PE Sc Received ck# Amount Date Permitl Invoice# P ► ME T <br /> Code INFO B emitted Service Requipst# <br /> 142 <br /> 0 3 IY (q ) . .0 RECEIV D <br /> APR 1 19 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />