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t , <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 CITY/ZIP <br /> CROSS STREET /Ge�T�/Cye�JJ�x�/�� /64. C' APN-044�> PARCEL SIZE -7 •� hey <br /> OWNER NAME S �Cjj��SCI�I PHONE f¢iQ � /G y <br /> OWNER ADDRESS SJR//L-*t2 CITY/STATEIZIP <br /> CONTRACTOR i9/7£{JL � S PHONE <br /> CONTRACTOR ADDRESS 371�� �vit /!/�/� CITY/STATE/ZIP c, �J7`y <br /> LICENSE VC-42 110C-36 OTHER NUMBER yS5VY� EXPIRATION DATE OV3%�`J <br /> � 1 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # IF BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: U NEW INSTALLATION REPAIRIADDITION U ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: 77X-RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CI�v� 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 4O ft <br /> t ^ <br /> DISTANCE TO NEAREST WELL ft FOUNDATION V�' ft PROPERTY LINE Sift 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 CZ) WIDTH (o ft LENGTH I-I— ft DEPTH k L ft <br /> // DISTANCE TO NEAREST WELL I r)& ft FOUNDATION_ yff ft -- PROPERTY LINE T 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 LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MIN111WM `} HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE G1/7ej9 <br /> Q <br /> I IN 4E IN-r <br /> RM <br /> ID PAR TMENT 11SEqA LY <br /> Application Accepted Date AreaEmployee ID# <br /> • <br /> Final Inspection By Date ❑ StIAL RMIT- pproved by <br /> Character of Soil to epthof 3 Ft: Pi Sum Soil Charact <br /> COMMENTS C_ <br /> L� <br /> �- <br /> PE SC ReceivedAmount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request42Li��_ L/,e> # <br /> .239-70 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />