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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 PXPIRES4 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I J 7 [ v' JS CITY/ZIP SC-a GY-) cc, <br /> CROSS STREET r S t /� APN G L Ji �j / PARCE[L/SIZE tz <br /> OWNER NAME V//�-- �T✓ C/� ✓ I PHON 0-0 <br /> OWNER ADDRESS Z/([/� y /���1 CITY/STATE/ZIP <br /> CONTRACTOR OWr1L� L ' lC PHONECZOJ// <br /> r <br /> CONTRACTOR ADDRESS t"nei( CITY/STATE/ZIP <br /> LICENSE 11❑C-42 ❑0C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coo rdinates X Y <br /> I-E PERC TEST # BUILDING PERMIT# t' LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION LI REPAIR/ADDITION L ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: )i3�,RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG L CAPAClTY/Zon CAPACITY/Zgal #OF COMPARTMENTS <br /> ® GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> �U LIFT STATION SIZE TYPE OF PUMP El PKG TX PLANT El SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> J LEACH LINES ❑ LEACHING CHAMBERS 1 #OF LINES 2 LENGTH OF LINES ft <br /> I/ \ DISTANCE TO NEAREST WELL 1 ft FOUNDATION 7t ft PROPERTY LINE ft <br /> D FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> O MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> RE <br /> DISTANCE TO NEAST WELL rft FOUNDATION ft PROP/ERTY IfyE ft <br /> SUMPS WIDTH / ft LENGTH Co/ ft DEPTH / / ft <br /> DISTANCE TO NEAREST WELL 5 V ft FOUNDATION Sd ft -- PROPERTY LINE �� ft <br /> 0 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 /> MDVLWM `{$ UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 d <br /> SIGNED TITLE DATE <br /> L. <br /> It t <br /> x <br /> ik 25 <br /> I 1A <br /> z <br /> PARTMENT USE j2Nk <br /> Application Accepted By Date 77 Areaq�r Employee ID# <br /> Final Inspection By_ Date 2 El SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 kv it/ ump Soil Character: nwVEIACAI'r <br /> COMMENTS RMEWED <br /> NOV 2 7 2018 <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO B Cash Remitted Date Service Request# Invoice# SA06 dW CO NTY <br /> �, q L <br /> 421L- 2 1Z DEPARTMENT <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br /> 2213y <br />