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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 MIT ALL 209 953-7697 FORINSPEC77ONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> C.ITY)ZIP y <br /> M <br /> CROSS STREET .nom APN (5 PARCEL SIZE <br /> LR 1`0�y 1 Z LG PHONE <br /> OWNER NAME { C c Ave <br /> /� �jd ( }� <br /> OWNER ADDRESS ' `� �+ 1 `� • ` _CITY/STATE21P/� L�rf" I� y"'�" S <br /> CONTRACTOR '�• PHONE 'z � i -�y4 <br /> CONTRACTOR ADORECITYISTATEZP,;, +�f T��(j�J� <br /> LICENSE 00,C-42 ❑LIC-36 JryOOTTHER 1 NUMBER ga2eE.PIRATION DATE <br /> WATER TABLE DEPTH: W ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# - LAND USE APPLICATION# <br /> TYPE OF WORK: ',,C NEW INSTALLATION a REPAIR/ADornON L! ENGINEER DESIGNED IALTERNATIVE <br /> REPLACEMENT OUT-OF-SERNCESEPTIC SYSTEM 0 DESTRUCTION <br /> INSTALLATION WILL SERVE: ` RESIDENCE 0 COMMERCIAL) I..] OTHER <br /> NUMBER OF LMNG UNITS: i NUMBER OF BEDROOMS: ! NUMBER OF EMPLOYEES: /J <br /> SEPTIC TANK TVPE/MFG CAPACITY A� gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY�_ gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL­ZP,12A ft FOUNDATION� ft PROPERTY LINE e- '-L ft <br /> �❑ LIFT STATION SIZE TYPE OF PUMP E3PKG TX PLANT Q SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> I Q LEACH LINES ] LEACHING CHAMBERS #OF LINES_(`� LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL /A�//T ft FOUNDATION ft PROPERTY LINE <br /> ❑ FILTER BED WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSALPONDS WIDTH it LENGTH ft DEPTH ft <br /> DISTANCE TO NET WELL ft�FOUNDATION R PROPERT ft <br /> SEEPAGE PITS NuMBER WIDTH ft DEPTH ..//LLjj It <br /> DISTANCE TO NEAREST WELL_It FOUNDATION�Q�_ft PROPERTYLINEv�--�- 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 /> ?ED FOR INSUC NS-PLEASE CALL(209)953-769 <br /> SIGNED TITLE /J DATE <br /> RWI <br /> D E PAA <br /> Application Accepted Data Er L •I / Areav! Employee ID# <br /> Final Inspection By Date z ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Amount Date PertniU Invoice# Permit IDX <br /> Code INFO Bv Cash Remitted -Service Reauest# <br /> In U1 Skit <br /> 42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4114118- <br />