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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 PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP L <br /> .a <br /> CROSS STREET / /r ' APN Q �� V✓ PARCEL SIZE c <br /> ]P. /I (S <br /> �n �pF <br /> OWNER NAME /uay✓I 1 r�� dyf PHONE i <br /> OWNER ADDRESS �T� Q� cr CITY/STATE/ZIP 'r V <br /> CONTRACTORG� PHONE " V I <br /> CONTRACTOR ADDRESS �/ CJ/SOyI (�j' CITY/STATE/ZIP <br /> LICENSE El�d-42 ❑l:C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: l �+' ft GEOGRAPHICAL INFORMATION: Coordinates X <br /> FE--P ERC TEST # BUILDING PERMIT# LAND USE APPLICATION <br /> TYPE OF WORK: NEW INSTALLATION I REPAIR/ADDITION ENGINEER DESIGNEd-MFTQA,0rIVE <br /> REPLACEMENT 1 OUT-OF-SERVICE SEPTIC SYSTEM DESTRUC <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL OTHER SAM, LLuu••'' <br /> NUMBER OF LIVING UNITS: I c NUMBER OF BEDROOMS: NUMBER OF k% <br /> L3 SEPTICTANK TYPE/MFG ��r-J��G CAPACITY ( (Y Ov gal #OF COM�heA1q NTA <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> \l LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES '7 6 / ft <br /> DISTANCE TO NEAREST WELL /00 ft FOUNDATION 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 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 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 �3 i ft DEPTH C?s ft <br /> DISTANCE TO NEAREST WELL /Sj ' 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS/ <br /> -PLEASE CALL 209 953-7697 G� <br /> SIGNED �— TITLE t!/I !C�6y DATE <br /> IV <br /> 41S <br /> IYA <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Final Inspection By l- Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Deptf,of 3 Ft: it/Sump Soil Character: <br /> COMMENTS <br /> PE Sc Received Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Cash Remitted Service ReRest <br /> I ,� . <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />