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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 /> MON-REFUNDABLE PERMIT CALL <br /> ,, ,, ++ CALL(209)953-7697 FOR INSPECTIONS �`� EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS to sp� / W�� ��(JQ^ QA . CITY/ZIP / 7�G�/J <br /> CROSS STREET I APN ZI�'� ��J PARCEL SIZE (j.0 p <br /> a <br /> OWNER NAME PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR `"L�DIc�AT' �� L �,//"�� ���� PHONE -�(o-f //'/e/r uL/ <br /> CONTRACTOR ADDRESS d"/ (/v'(-LV/CITY/STATE/ZIP 1� lay.. (: > -` <br /> LICENSE ❑I IC-42 11iC-36 OTHER NUMBER �(-�TJX EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: F1 NEW INSTALLATION G REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE <br /> ,o- REPLACEMENT I i OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION C- <br /> INSTALLATION WILL SERVE: V RESIDENCE ❑ COMMERCIAL /f_ OTHER <br /> NUMBER OF LIVING UNITS: �r NUMBER OF BEDROOMS: /v _ NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MPG /• f �n 1�i/G� CAPACITY ! e;C-2J gal #OF COMPARTMENTS '-I— <br /> L3 <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL C/90 ft FOUNDATION Z ft PROPERTY LINE --�c� ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 41t LEACH LINES I LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION -5c-` ft PROPERTY LINE S 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 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE / DATE <br /> / /N C <br /> E <br /> N <br /> fD PARTMENT SE 0A LY <br /> Application Accepted By. / Date Area Employee ID# <br /> Final Inspection By ?� Date ❑ SPE IAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 t: _ Pit/Sump Soil Character: <br /> CONII\�IF_INTS - <br /> - . <br /> PE SC Received Check#/ AmOunt Date Permit/ Invoice# Permit ID# <br /> Code INFO a Remitted / Service Re nest# <br /> ?�a ( <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />