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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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE(ISSUED <br /> JOB ADDRESS Irte - CITYIZIP `7 / / `/� o 7 y <br /> m <br /> CROSS STREET �,tl /l`� APN Xq ao 2! PARCEL SIZE C)G K U C <br /> 76-2— <br /> OWNER NAME 12 f°QC� ✓ <br /> PHONE v <br /> OWNER ADDRESS �/�"o `,I- �/*S ��['�t n✓�L­ CITY/STATE/ZIP <br /> CONTRACTO MZ4 - PHONEoZo`7 <br /> CONTRACTOR ADDRESS �� /�V� CITY/STATE/ZIP <br /> LICENSE ❑❑C-42 11❑C-36 OTHER NUMBER 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: u NEW INSTALLATION L REPAIRIADDITION ❑ 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 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 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT I HAVE PRZDVANCE <br /> THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> ATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> UM 24 H R N TICS REQUIRED FOR INSPECTIOgNS-PLEASE CALL 209 9 <br /> 953-7 7 <br /> SIGNED �� TITLE �/ ` e".1, DATE <br /> Ae <br /> A PA <br /> a F <br /> O 4' <br /> A N <br /> DEPARTMENT USE ON Y <br /> Application Accepted B — Date Area Employee ID# <br /> Final Inspection By Date7111 <br /> ❑ SPE IAL PERMIT-Approved by <br /> Character of Soil to Dep h of 3 Ft: P Sump Soil Characte <br /> f <br /> COMMENTS Ll <br /> PE SC Received C Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By, Lj Remitted Service Request# <br /> 7 Z,� <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />