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M <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 CALL209 NS 953-7697 FOR INSPECTIO <br />�»�a� � EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS• ,Q _ CITY%LIP LGt C; ' Q <br />CROSS STREt �APN�3_— <br />OWNER NAME — — PARCELSIZE—J• <br />-- <br />_ 5 <br />PHONE / <br />OWNER ADORESS !�!�Ltt� _ l -e} CITY/STATE/ZIP G O <br />CONTRACTOR �' `�S 13Q —_ <br />PHONE <br />CONTRACTOR ADDRESS _CITY/STATE/ZIP <br />LICENSE FIC -42 CC -36 OTHER NUMBER _EXPIRATION DATE <br />WATER TABLE DEPTH: <br />F1 PERC TEST B <br />it GEOGRAPHICAL INFORMATION: Coordinates X Y <br />oUILUINU YEHMIT IT _ LAND USE APPLICATION # <br />-I .._.... •­^ I' MLPAIRIADDITION ENGINEER DESIGNE0/ALTERNATIVE <br />C REPLACEMENT _ OUT -OF -SERVICE SEPTIC SYSTEM . 1 DESTRUCTION _ <br />INSTALLATION WILL SERVE: ❑ RESIDENCE n COMMERCIAL OTHER JI }' <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBEn OF MPLOYEES: <br />k— SEPTIC TANK TYPE/MFG CAPACITY _ 2 v gal # OF COMPARTMENTS _ <br />❑ GREASE TRAP TYPE/MFG _ CAPACI I Y gal # OF COMPARTMENTS_ <br />DISTANCE TO NEAREST: WELL _ It FOUNUATION __ it PROPERTY LINE It <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />QS LEACH LINES ; LEACHING CHAMBERS <br /># OF LINES �_ LENGTH OF LINES it <br />DISTANCE TO NEAREST WELL <br />_ i[ FOUNDATION _1D it PROPERTY LINE_ it <br />❑ FILTER BED WIDTH —__ it LENGTH <br />._ <br />_ft DEPTH . it <br />DISTANCE TO NEAREST WELL <br />it FOUNDATION ft PROrcnTYLINE_ It <br />❑ MOUNDED WIDTH __ 1t LENGTH <br />it DEPTH _ ft <br />DISTANCE TO NEAREST WELL <br />h FOUNDAI ION it PROPERTY LINE it <br />❑ SUMPS WIDYH - __ K LENGTH <br />It DEPTH, _ II <br />DISTANCE TO NEAREST WELL <br />ft rOUNDATION ft PROPERTY LINE 11 <br />❑ DISPOSAL PONDS WIDTH __ it LENGTIi <br />_ ft DEP IH It <br />DISTANCE TO NEAREST WELL <br />it FOUNDATION it PROPERTY LINE ft <br />® SEEPAGE PITS NUMBERWmrH <br />it DErn I 0 <br />DISTANCE TO NE REST WELL <br />it r-OUNDATION_.h PROPERTYIINF it <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 />MINIUUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-76L97 <br />SIGNED <br />TITLE--OLA/,I/ /Z- DATE <br />DEPARTMIENT USE ONLY ��" <br />Application AccqtoD <br />Dateit 1 Area 00¢' 9 Employee ID# <br />Final Inspection Date ! F1 SPECIAL PERMIT -Approved by <br />Character of Soilth of3 Ft: Pit/Sump Soil Character: <br />COMMENTS AA o—) <br />PE SC Received hec # Amount Date Permit/ Invoice # Permit ID# <br />Code INFO By CBS F Remitted Service Request # <br />f <br />42-01 ONSITE WAS IEWATER TRTMNT SYSTEM PERMIT <br />4/24/12 <br />