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T 0N,,,w!TEWASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRC-NNIENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-RZFUNDABLE PERMIT CALL '205 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS O CITY/ZIP ��� J <br /> =1 <br /> CROSS STREET [/J.�_V/Y/1, ��jJ.�7,/� '//� APN O�t JZ 3 00) _PARCEL SIZE �Q• p <br /> OWNER NAME Y/��IG1 ? reP9dO � z <br /> PHONE M. <br /> OWNER ADDRESS —CITY/STATE/ZIP,AC <br /> CONTRACTOR 1• u' G PHONEy ` <br /> CONTRACTOR ADDRESS "�[/� /, CITY/STATE/ZIP . <br /> LICENSE oX-42 I C-36 OTHER NUMBER f JI EXPIRATION 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 REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: n RESIDENCE I COMMERCIAL Ll OTHER <br /> NUMBER OF LIVING UNITS: -t 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 It 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 `,� LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL DO ' ft FOUNDATION [ILD/ 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 it <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 It <br /> DISTANCE TO NEAR T WELL ft FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER ` WIDTH .� , ,n ft DEPTH eY� _ It <br /> DISTANCE TO NEAREST WELL ISD ft FOUNDATION CYO ft PROPERTY LINE Jy 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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE <br /> 20 V <br /> JUN <br /> [NJ <br /> ry <br /> EP VfN <br /> TH DEo FN <br /> DEPARTMENT USE ONLY <br /> Application Accepted y � L Date U0 Z Z 2 0 Area �r Employee ID# Df-i <br /> )o I i SPECIAL PERMIT-Approved b <br /> Final Inspection By � Date"``"'Ii pp y <br /> Character of Soil to De th of 3 Ft: it/Sump Soil Character: _ <br /> COMMENTS <br /> � <br /> PE SC ReceivedChec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />