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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 EXPI REP 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP 1' <br /> CROSS STREET /-4 c d APN jOirm ' I PARCEL SIZE d <br /> OWNER NAME r e-C l-)q PHONE !/ <br /> / <br /> OWNER ADDRESS (71 4,'/ <br /> � n��(/l,U-r,, V Gc I CITY/STATE/ZIP <br /> CONTRACTOR T%(� 4/r/// I'� ��/- PHONE <br /> CONTRACTOR ADDRESS r� CITY/STATE/ZIP C <br /> LICENSE 110C-42OC-42 ❑❑C-36 OTHER NUMBERS,?.? 0.3 Z 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: L NEW INSTALLATION a REPAIRIADDITION L1 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 /> SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL G�b�f ft FOUNDATION_ ft PROPERTY LINE 17It 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 I ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION (�f ft PROPERTY LINE !2 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 fl 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 /> EA <br /> /qp`[ SEEPAGE PITS NUMBER :/ WIDTH '-b fl DEPTH v7, ft <br /> DISTANCE TO NEAREST WELLJj(:�_ ft FOUNDATION {eft 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 /> TE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMU `{$I-IOIJ ® ST C T10E REQUIRED FOR INSPECTIONS--PLEASE CALL 209 953-7697 <br /> SIGNED TITL <br /> r2nin <br /> F® <br /> J <br /> Rwul OUIV <br /> r <br /> P Iq,M NT <br /> EPARTMENT SE JN Y <br /> Application Accepted By Date Area Employee ID# <br /> Final Inspection By Date ❑ SPEC ALP MIT-Approved by <br /> Character of Soil to De hof 3 Ft: 'PitjSump Soil Character: <br /> COMMENTS <br /> PE Sc Received he Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Re uest# <br /> 0805 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />