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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 �� �,J ��' CITYIZIP ���+ rn <br /> q <br /> _ t=t <br /> CROSS STREET IU APN �_/ PARCEL SIZE_ _C p <br /> OWNER NAME �r'C L r�r C"�e -� PHONE <br /> OWNER ADDRESS / CITYISTATEIZiP `` <br /> CONTRACTOR !� �i d �e W(/ PHONE -2 7 u <br /> CONTRACTOR ADDRESS i CITY/STATE/ZIP ♦/ jA <br /> LICENSE �C-42 IJC-36 OTHER NUMBER )J' f EXPIRATION DATE '( / <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> 0 PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ie- REPASRIADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT bS D r C"LL, ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE �$OMMERCIAL 11 OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gel #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gai #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> © LIFT STATION SIZE TYPE OF PUMP U PKG TX PLANT ZI SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ja LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES €f <br /> F� DISTANCE TO,NEAREST WELL 10 U �' OU ATION I`D ft PROPERTY LINE_ ft <br /> BEDWIDTH / o ft LENGTH O ft DEPTH / '� l��c- ft <br /> DISTAN E TO EAREST WELL / ft F i7ATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO__ ST WELL ft FOUNDATION ft PROPERTY UNE ft <br /> WIDTH ff LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL 10 0 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 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 /> MINIMUM OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEAS CALL(209)953-7697 _?/1.2 3_ <br /> I I <br /> SIGNED TITLE _ N '� DATE <br /> L <br /> NY 1 1 4M <br /> E! <br /> Env <br /> O Q IN <br /> TM DE <br /> TV <br /> H+kH <br /> DEPARTMENT SE O Y C n [� / <br /> Application Accepted By _, �� ate ti Area Em0 CT 5 <br /> Employee ID# r <br /> Final Inspection By 4: Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Deoth of 3 Ft: P Sump Soil Character: <br /> COM NTS �� Lo`r � <br /> PE SC Received _Qh_eAmount Permit/ <br /> Code INFO By Cash Remitted Date Service Re uest# Invoice# Permit ID# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 1014107 <br />