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ONSITE WAMEWATER TREATMENT SYM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT ARTMENT 600 N STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 0 1 CITY/ZIP v <br /> CROSS STREET �I �^ I nn ,^, APN ��S O2b,�� PARCEL SIZE <br /> OWNER NAME 1--k'p-OC( 04e c---- CnA ) PHONE 2///YJf zliri7— 21r> <br /> OWNER ADDRESS CITY/STATEIZIP / G� ( ,�/ 2� <br /> r <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE QC-42 QC-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: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT D OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: <br /> El RESIDENCE El COMMERCIAL 11 OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASETRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFTSTATION SIZE TYPE OF PUMP ❑ PKGTXPLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES it <br /> DISTANCE TO NEAREST WELL it FOUNDATION 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 It PROPERTY LINE ft <br /> ❑ SUMPS - WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH it 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 /> 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 /> MINIAM&M 24 H R ADV NCE NOTICE RE UIRED FOR INSPECTIONS- PLEASE CALL 209 953-7697 <br /> SIGNED TITLE g2e! //✓ DATE/Z <br /> t; Niq P <br /> A SA OA L <br /> H TH DE <br /> EPAR TMENTU E LY <br /> Application Accep'03 <br /> Date Area Employee ID#� <br /> Final Inspection BDate _ Z ❑Are; <br /> PERMIT-Approved by <br /> Character of Soil tPit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received - Chao Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By ash Remitted Service Request# <br /> II D 6AWV l5 <br /> 42-01 , - ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 9/21/10 <br />