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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 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 J' \GFS CITY/ZIP at' y <br /> {1�` / Q NPN CROSS STREET <br /> /� p <br /> OWNER NAME 1 �r�A^ �`•^'� PHONE <br /> OWNER ADDRESS <br /> ` MCITY/STATEIZJP'�'� c,l' <br /> CONTRACTOR Os !wwU1)A t YL ry-W PHONE I 0 3 <br /> ` <br /> CONTRACTOR ADDRESS ("ID 6Y. 1� CITY/STATE/ZIP ��� ? C''/} I �-5 3 -!— <br /> Ic <br /> ��LICENSE 1 C-42 I1 C-36 OTHER µ( NUMBER 01�510A EXPIRATION DATE ^ <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> d <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DES IG ED/ALT ERNATIV <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: J RESIDENCE I COMMERCIAL 1 OTHER �J <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG 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 O PKG TX PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION It 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 X <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 <br /> 1 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 /> VgWUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 QQ <br /> SIGNED TITLE DATE <br /> A,qY� <br /> FcZ'o?v <br /> C,8 FO <br /> N <br /> j <br /> N,L /Cv <br /> pqR TTY <br /> QA <br /> PARTM A.NT SE N <br /> Application Accepted By Date 2i A ( a e Employee ID# <br /> Final Inspection By Date F EC AL ERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PiUSump Soil Character: <br /> COMMENTS <br /> PE SC ReceivedChec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO ash Remitted Serviceuest# <br /> J t � <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />