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Zh�Fw�\ S�.ar 1-1-17 �il� <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 YEFROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP k m <br /> CROSS STREET 1/t ,' APN IJ�O 0 PPARCCELQSIZEt r p <br /> OWNER NAME /I/OV� (/I/GJ' 1 /'�L dYC-=iY'�CI�T- PHONE <br /> OWNER ADDRESS CDY/STATEIZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS 'FIC' CITY/STATE/ZIP <br /> LICENSE 1111C-42 OCC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION N REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT C 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 /> ❑ GREASETRAP 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 #OFLINEs LENGTHOFLINES it <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE It <br /> ❑ FILTER BED WIDTH it LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH it DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH it LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH 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 SANJOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLEP W.-V DATE 2 --/T�/ <br /> 3 r <br /> 3� <br /> All <br /> Ol <br /> LrARTMENT E ONLY n <br /> Application Accepted Date Area Employee ID byllo� <br /> Final Inspection By Date ❑ SP CIAL ARMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/ Amount PermiU <br /> Code INFO B Cash Remitted Date Service Re uest# Invoice# Permit lD# <br /> II s vo <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />