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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABL PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS41-�7 104 CITY/ZIP !/7oz i 4 S <br /> CROSS STREET/CbE3Ii _ APN�; I �J PARCEL SIZE <br /> OWNER NAME'e )'—�.GS/,4 i,q 0 ?AUL_ PHONE <br /> OWNER ADDRESS(`f��/I�i __-CITY/STATE/ZIP _ <br /> CONTRACTOR /� / (1/Ci/ ���1� /'�j �� �1'L PHONE <br /> /n <br /> CONTRACTOR ADDRESS //ifiC� r _ _ _ CITY/STATE/ZIP. O� nv� <br /> LICENSE et!C-42 1 C-36 OTHER� NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: (OUft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> I PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED AL <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION r <br /> INSTALLATION WILL SERVE: :�ESIDENCE COMMERCIAAL� 1 OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: .J NUMBER OF EMPLOYEES:� <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPA[t NW <br /> ❑ GREASE TRAP TYPE/MFG _ CAPACITY gal #OF COMPA",i <br /> HL <br /> DISTANCE TO NEAREST: WELL _ It FOUNDATION ft PROPERTY LINE EPARTw'.p <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES I I LEACHING CHAMBERS _ #OF LINES / LENGTH OF LINES �` ft <br /> DISTANCE TO NEAREST WELL,�>� ft FOUNDATION !/ v ft PROPERTY LINE It <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH It LENGTH ft DEPTH_ _ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ SUMPS WIDTH ft LENGTH It DEPTH It <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 f� FOUNDATION ft PROPERTY LINE It <br /> ❑ SEEPAGE PITS NUMBER �� WIDTH J ft DEPTH �Lh ' ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION //1—L -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 /> MINMUM 24 HOUR ADVAOICE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED n TITLE ��G CI DATE <br /> � I - <br /> EPARTMENTS -AIL I ONLY <br /> Application Accepted By Date ff Area Employee ID# <br /> Final Inspection By l Date_ zU I 1 SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> oe <br /> � �D'>�9� 6wa C- V&,- <br /> PE SC Received ('-ChecWP Amount Permit]C7ode INFO B C7as emitted ^ Date Service Request# Invoice# Permit ID# <br /> !i � D "rJ <br /> 42-01 ONSITL WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />