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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABL PERMIT CALL 209 953-7697 FOR INSPECTIONS ExPP'IRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 7-L CITY/ZIP 70 e- i 6) <br /> CROSS STREET <br /> ��b /1E�_pc�/i �1 APN 10; Q /5' <br /> PARCEL SIZE <br /> OWNER NAME.r`-/ r /q//V,.4Z.4 a ?AUL- PHONE .L- <br /> OWNER ADDRESS �� -CITY/STATE//ZIP <br /> CONTRACTOR / /%/(i/{j���1� /"�/ -IA �LG ___ PHONE <br /> CONTRACTOR ADDRESS �L/ ��//�� //diC� _ _ CITY/STATE/ZIP <br /> LICENSE et!C-42 L,-C-36 OTHER�T� NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: (OUft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> _l PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ � <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION I <br /> IVEFPINSTALLATION WILL SERVE: �kESIDENCE 1 l COMMERCIAAL� l i OTHER A <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: .J NUMBER OF EMPLOYEES: <br /> ��"�- <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTNtL�,,��� <br /> Cojjjv <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPAI NWrl0 <br /> DISTANCE TO NEAREST: WELL - It FOUNDATION ft PROPERTY LINE H EPARTMENItt <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES I'. LEACHING CHAMBERS _ #OF LINES / LENGTH OF LINES �` 4 ft <br /> ��� 7 -� <br /> DISTANCE TO NEAREST WELL ft FOUNDATION !/ v It PROPERTY LINE It <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH It LENGTH ft DEPTH_ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ SUMPS WIDTH ft LENGTH It DEPTH It <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 It <br /> ❑ SEEPAGE PITS NUMBER 4-- WIDTH ♦ / ft DEPTH ,Lh _- It <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 /> MINLUUM 24 HOUR ADVAOICE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE <br /> \ I - <br /> ti <br /> EPARTMENT S - ONLY <br /> Application Accepted By Date f Area Employee ID# <br /> Final Inspection By - `'�' Date 1 SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE Sc Received ("Check# Amount Permit] <br /> Code INFO B �7as emitted Date Service Re uest# Invoice# Permit ID# <br /> 4Z10D "JI-1A <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />