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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES/1 YEAR FROM DATE ISSUED <br /> pCITYIZIP <br /> JOB ADDRESS x, 550 � ����^4"� I Q I <br /> CROSS STREET �J `1CIrF� ►�'• �v APN PARCEL SIZE - o <br /> 4^ _PHONE ti <br /> OWNER NAME / ap-e m r y <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR , I , C PHONE ;4; 2 <br /> CONTRACTOR ADDRESS C2 I `�G. CITY/STATE/ZIP <br /> LICENSE VC-42 C-36 OTHER NUMBER1-<!10 WEXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION D REPAIR/ADDITION G ENGINEER DESIGNED/ALTERNATIVE <br /> Li REPLACEMENT �i DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL OTHER <br /> / <br /> NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: 3 //-- NUMBER OF EMPLOYEES: <br /> SEPTICTANK TYPE/MFG Z-o e CAPACITY �(YC3C� gal #OF COMPARTMENTS <br /> LJ GREASE TRAP TYPE/MFG y r7�7 CAPACITY /�/, gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL I /lJ` It FOUNDATION !?T ft PROPERTY LINE /00/ 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 z/0 — ft <br /> &S ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION -SD'f ft PROPERTY LINE <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 It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER 4 WIDTH ft DEPTH �s, ft <br /> DISTANCE TO NEAREST WELL21'-S FOUNDATION /'7 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 /> MINIMUM 24Z ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE 3 <br /> WT- <br /> f — <br /> 5 ' <br /> c <br /> _ ENT <br /> IVSD <br /> iz- I 5 2015 <br /> IN COUNTY <br /> ENTAL <br /> DEPARTMENT USE ONLY pAnTMENT <br /> Application Accey i Date Area G Employee ID <br /> Final Inspection By < Date CJ SPECIAL PERMIT-Approved by <br /> Character of Soil to D pth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS �� <br /> itt � L s 5 <br /> PE Sc Received heck#/ Amount DatePermit/ Invoice# Permit ID# <br /> Code INFO B as Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 10/4/07 <br />