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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 PERMIT CALL (Q209 953-7697 FOR INSPECTIONS <br /> `C EXPIRES 1 YEAR/FROM DATE ISSUED <br /> JOB ADDRESS �F•� (1•• "tJ CITY/ZIP . h-., l<fr n 1 Cvt- <br /> CROSS STREE IPN V vV PARCEL SIZE d <br /> hd <br /> OWNER NAME PHONE <br /> OWNER ADDRESS P UGrtJL !� CITY/STATE/ZIP <br /> S—y � <br /> CONTRACTOR 41 '1 _ -4:1-)3-r 3L— PHONE J(is � �G•S <br /> CONTRACTOR ADDRESS Ci 5T) CITY/STATE/ZIP ll ^�+—[A �G✓I �.3fc <br /> LICENSE ❑❑C-42 ❑❑C-36 OTHER NUMBER ,EXPIRATIONDATE 62i7!7 <br /> WATER TABLE DEPT!I. jS 2D DEPT!. ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST F BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: u NEW INSTALLATION REPAIR/ADDITION U ENGINEER DESIG1K <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: U IKESIDENCE ❑ COMMERCIAL ❑ OTHER DEC <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMP X51:: , <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COfvfJPAArger�t�pj$JIUIUr-�p <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COP AR7M li PARTMFNr <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT L3 SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES �O! ft <br /> DISTANCE TO NEAREST WELL f7' ft FOUNDATION I O 1 ft PROPERTY LINE to! 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 /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> V/SEEPAGE PITS NUMBER _ WIDTH L tI fl DEPTH a-S I ft <br /> DISTANCE TO NEAREST WELL L�n- ft FOUNDATION 101 ft PROPERTY LINE U 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 43 U DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED - TITLE 40 DATE QL <br /> Sa <br /> Irn -ill <br /> 5 t <br /> EPARTMENT WE CYNY <br /> Application Accepted Date Area Employee ID#JAL� <br /> Final Inspection By"A?�� Date'6 Z t2lZ y ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PitlSump Soil Character: <br /> COMMENTS <br /> PE SC Received Check Amount Permit/ <br /> Code INFO Date ash emitted Service Request# Invoice# Permit ID# <br /> D12 7 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />