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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 PERMITT�, CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS >J�OD f��/�clC/C � - CITY/ZIP z�' - �O <br /> CROSS STREET 9�tG �O/ �� �� APN _(/ � D I �O PARCEL SIZE r p <br /> d <br /> OWNER NAME ZCrU 2. PHONE <br /> v <br /> OWNER ADDRESS CITYISTATE/ZIP `\�^ <br /> CONTRACTOR bf�/iL ///7/�cs =./l�'� PHONE �`j <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP J�ayL� wv <br /> LICENSE ❑ CC-42 ❑❑C-36 OTHER NUMBER V"6'1!;7- EXPIRATION DATE Oj/S/��j <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 REPAIR/ADDITION L ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ 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 �l 7/�//ivy 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 ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ,G--LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES L/G ft <br /> DISTANCE TO NEAREST WELL �/; /'V--- ft FOUNDATION SD 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 fl LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft -- PROPERTY LINE ft <br /> ❑ DISPOSALPONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL �7 ft FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBJ <br /> ER S WIDTH -36 ,( <br /> ft DEPTH ,-P�e ft <br /> DISTANCE TO NEAREST WELL—,25K--'= ft FOUNDATION ft PROPERTY LINE <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 ` eHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL (209)953-7697 <br /> SIGNED TITLE DATE /ezv €� <br /> J <br /> "ARE <br /> NT <br /> IMPIED <br /> 26% <br /> —SOLQ IN COUNTY <br /> NTAL <br /> E VI O M TMENT <br /> DEPARTMENT USE ONLY 2 PAR <br /> Application Accepted By Date UI Area q Employee ID# Lk) <br /> Final Inspection By &M746l2 Date 12�S J 2C 11SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Cade INFO B Cash Remitted Service Request# <br /> 42-10 11 0 12 a� <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />