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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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 7(� CITYIZIP fO <br /> H <br /> CROSS STREET LTG� D/�1 C 1 t / APN — & " 31 PARCEL SIZE d <br /> tj <br /> OWNER NAME PHONE <br /> OWNER ADDRESS ���7� CITYISTATE/ZII�P���-�/>GL�// <br /> CONTRACTOR SI:Z� PHONE 6/7 - <br /> CONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE ❑OC-42 110C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMAT oordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: Li NEW INSTALLATION LJ R P URIADDITION Li ENGINEER DESIGNED IAL ERNATIV <br /> REPLACE!Cr <br /> ❑ OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL �j 11'OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: / NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG P CAPACITY J�SnO gal #OF COMPARTMENTS 2- <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 0 PKG TX PLANT ® SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES S ft <br /> DISTANCE TO NEAREST WELL &)0 ft FOUNDATION 10 I- 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 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 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER '3 WIDTH ft DEPTH 1S ft <br /> DISTANCE TO NEAREST WELL ZSR ft FOUNDATION /0 ft PROPERTY LINE S 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 /> M AIIMU `13HOUR A IVA'NCE NOTICE REQUIRED FOR IN PECTIOIVS-PLEASE CALL 209 953-7697 cy <br /> SIGNED TITLE �2�: DATX"?—'- - <br /> 10 <br /> JAUN 011. <br /> HE ALF w <br /> PARTMEN SE N Y <br /> Application Accepted By �5&�A Date t Area Employee ID# <br /> Final Inspection By Date y❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to De of F1.. tl u'p Soil Character: <br /> COMMENT JIMMMMA,62 AJO <br /> l t o 5' r(7 r k <br /> PE SC Received -Chece Amount Permit/ <br /> Code INFO Cash emitted Date Service Re uest# Invoice# Permit ID# <br /> 1052 -1�1�1-I°l S12 S� l <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />