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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 17 UG 0-1 ie �CIL�P CITY/ZIP t ��l17 <br /> CROSS STREET �� (//JQ� / V APN 2`7-!� l ` U ZCJ PARCEL SIZE ty <br /> OWNER NAME CW(Q W <br /> l y� HONE <br /> OWNER ADDRESS C G. P'� V�� CITY/STATE/ZIP ` <br /> CONTRACTOR I,&46!� PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 00C-42 ❑DC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH:'�t J �3V ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT## VOLAND USE APPLICATION## <br /> TYPE OF WORK: U NEW INSTALLATION L REPAIRIADDITION Ll ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERC L ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG G CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL7 . ft FOUNDATION © + ft PROPERTY LINE AIV'e 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 LINESft <br /> ` DISTANCE TO NEAREST WELL �`"'- ft FOUNDATION O t 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 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 /> MIN HQW&AW OWE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 9A3-7697 <br /> SIGNE TITLE c����-E' DATE <br /> �Hr <br /> Fo <br /> e 2419 <br /> T UNC, <br /> Nr <br /> D ARTMENT SE L <br /> Application Accepted By ate Area Employee ID# <br /> Final Inspection By k A Date I ❑ SPE IAL PERMIT-Approved by <br /> Character of Soil�DepthFt: it/Suo p Soil Character: <br /> COMMENTS <br /> U <br /> PE Sc Received heck#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />