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r � <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 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> -31/ e� �1CITTY//.ZIP `l`Ci <br /> CROSS STREET APN,7clj PARCEL SIZE it'd <br /> OWNER NAME ' /1�Jz PHONE j✓ > U <br /> OWNER ADDRESS ��� � y2 Yyr�+e� CITY/STATE/ZIP � �� .64 J <br /> CONTRACTOR � � PHONE <br /> CONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE [IF-C-42 111IC-36 OTHER NUMBER EXPIRATION DATE <br /> 4 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # ' BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: �C NEW INSTALLATION REPAIR/ADDITION I_l ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM u 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 O 0 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 ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> UK LEACH LINES LEACHING CHAMBERS #OF LINES�— LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL 100 ft FOUNDATION V 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 FOUNDATIQN ft PROPERTY LINE ft <br /> l � <br /> SEEPAGE PITS NUMBER WIDTH 2 ft DEPTH ft�-^- <br /> DISTANCE TO NEAREST WELL13 ft FOUNDATION Ito PROPERTY LINE J 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 /> MINIMUM 48 HQN0961E REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-769/7 <br /> SIGN TITLE DATE <br /> J <br /> R &AU <br /> P <br /> EPARTMENT USE O ILY <br /> Application Accepted By Date2� Area ` Employee ID# G <br /> Final Inspection By I Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth oft: Pit/Sump Soil Character: n <br /> COMMENTS <br /> 1 PE SC Received otheck#0 Amount Permit/Code INFO B Remitted Date Service Request# Invoice# Permit ID# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/13 <br />