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11 <br /> 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 /> JOB ADDRESS �L.�) CITYIZIP S27�O 5, <br /> ((]] Ap toy <br /> CROSS STREET -I ��'� e APN� 7O^/✓ PARCEL SICZE' 2 •�L b <br /> OWNER NAME Lr r [)I (�'�Q`r� /'7 I PHONE 209- �1d310- '9SW 7 <br /> OWNERADDRESS ZZs% r FOres4 L +4_ 2d CDYISTATEILP �• c2 C;4 ,izzo <br /> CONTRACTOR �EIT �w PHONE ��'�I�S <br /> CONTRACTOR ADDRESS CITYISTATE21P <br /> LICENSE CDC-42 QC-36 OTHER NUMBER E%PIRATION 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 REPAIRIADDITION 11NED(ALTE <br /> ENGINEER DESIGRNATIVE <br /> ❑ REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG CAPACITY gal #OFCOMPARTMENTS Z- <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES 2— LENGTH OF LINES go it <br /> DISTANCE TO NEAREST WELL ft 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 It 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 it PROPERTY LINE it <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION-ft PROPERTY LINE ft <br /> SEEPAGEPITS NUMBER 2 WIDTH3611 ft DEPTH 2.$ / ft <br /> DISTANCE TO NEAREST WELL Ze0 ft FOUNDATION 56 ft PROPERTY LINE S81 it <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 /> INIMr 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNE WTITLE 0 wwe'r DATE <br /> 1/111 OA <br /> 5 <br /> U TV <br /> H DIF INT <br /> DEPARTMENT E ONLY <br /> Application Accepted Date Yr� Area Employee 0# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to epthof 3 Ft: PiVSump Soil Character: <br /> COMMENTS / -Apo <br /> PE SC Received Che / Amount Date PermiU Invoice# Permit ID# <br /> Code INFO B as Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 10/4/07 <br />