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3� 1 5(&' 1-30-17 �� <br /> I 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 PER T CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATq ISSUED <br /> JOB ADDRESS A W✓ �i. C�1r� yJ 4 S <br /> CROSS STREET APN T� 6 PARCEL SIZE p <br /> v <br /> ^� z <br /> OWNER NAME 0 L4 UlJPHONE <br /> OWNER ADDRESS-g�";�4Z D C—tA., CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑ C-42 ❑ C-36 OTHER NUMBER 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 DESI"ED/ALTER ATIV <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION 1L . <br /> INSTALLATION WILL SERVE: i I RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: 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 _- D <br /> O N ,AY INE*---j .OlytF'74 (ENCLOSED SYSTEM ft <br /> L3 LIFTSTATION SIZE TYPE OF PUMP ❑ A ,+ <br /> Permit <br /> ❑ LEACH LINES LEACHING CHAMBERS � j{ Q{� (y n(� }�, It <br /> DISTANCE TO NEAREST WELL ft � r WI ("Ulf]" Q�T[."U E ft <br /> ❑ FILTER BED WIDTH ft LENGTH by Lnvlronmen uh�� 6 It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft 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 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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-76 <br /> SIGNED TITLE PGA DATE n 1 <br /> 79 <br /> R <br /> a DEPARTMENT USE ' NLY /� T <br /> Application Accepted Date b Area rl Employee ID#�l� <br /> Final Inspection By Date 7- ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received heck#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Remitted Service Request# <br /> S oo () g <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />