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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1965 E HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 9 YE FRO D ISSUED <br /> JOB ADDRESSL CIITYIZPPf �) <br /> CROSS STREET Aj VE APN `�' PARCEL SIZE C y <br /> OWNER NAME /YI{7 Jz lc� u I'�.- ' PH <br /> OWNER ADDRESS la0t � ��� "'"�-' ""' CITYISTATEI7JP �%�' <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITYISTATEI7JP <br /> LICENSE 13❑C42 CCC-36 OTHER NUMBER 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 LI REPAWADDITION UENGINEER DESIGNED IALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM VC DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> Q GREASE TRAP TYPEIMFG CAPACITY Jai #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_ Amp- it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 7MEArr <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH �1SR <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINEUL,I ft <br /> L3 MOUNDED WIDTH ft LENGTH ft DEPTH ee,,��,,.. /IIn?ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY L14AN ft <br /> ❑ SUMPS WIDTH R LENGTH ft DEPTH tI <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ DISPOSALPONDS 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 /> 1 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 /> WNIMUM`�_g HOUR 61VA NOTICE REWIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE !7i �*_ DATE b'I�'r <br /> i <br /> I <br /> PAR7MENT lag2mky <br /> Application Accepted By Date d Area Employee ID# <br /> Final Inspection By Date ' , ❑ SPE AL PERMIT-Approved by <br /> Character of Soil too" <br /> Ft ip USu Soil Character: <br /> ep <br /> COMMENTS , /&4&1,1 /2sf' <br /> PE 5C Received Check#I Amount Parm(U Invoice# Permit ID# <br /> Code INFO Cash em' Date Service uost# <br /> tC3 tt ? <br /> Ii <br /> 42_01 .*8.3ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4124112 <br />