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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 O i /L CITY/ZIP S roG TOIL rA <br /> C c H <br /> CROSS STREET 5 Oa APN/Z 9,� �7 �d� PARCEL SIZE a <br /> d <br /> 9? 7 yd <br /> OWNER NAME elf L A T/OAJ �[�,5 Tid/G ? ;7ZAF PHONE /�� •^+ ���" N <br /> OWNER ADDRESS 3Y.3 ,�", I%/4//� J� T/2E�! CITY/STATE/ZIP <br /> CONTRACTOR PHONE -z G' %— <br /> CONTRACTOR ADDRESS X CITY/STATE/ZIP <br /> LICENSE 110C-42 110C-36 OTHER G 'ZI NUMBER 719 Z/ 3 .EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: U NEW INSTALLATION a REPAIR/ADDITION L ,E'IqGINEER DESIG D/ALT RNA IVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM a 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 E3 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 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 /> MINIM `{$ UR -REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7 <br /> &97 <br /> SIGNED TITLE Lff /l/J�LrO�GgTE / / <br /> r <br /> ol <br /> Q ,n, <br /> N I <br /> � <br /> H <br /> Er <br /> DEPARTMENT USA ON Y <br /> r <br /> Application Accepted DateArea Employee ID# — <br /> Final Inspection By Date ❑ SPE AL PERMIT-Approved by <br /> Character of Soil toDepthof 3 Ft:r PitlSump Soil Character: <br /> COMMENTS ) <br /> / - D�v► <br /> LC 4- - OU c. / I. n <br /> PE SC Received Checic#/ Amou'lit Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> SSC - (q <br /> 42-01 I r r / I l 3 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />