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c <br /> 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 q EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 41 jo C' l V e CITY/ZIP /s 3 O �SG°L< '17 <br /> CROSS STREET APN �� [ _ J _PARCEL SIZE1_ p <br /> �/ 7 0 <br /> e. C Q PHONE / r-- / v, <br /> OWNER NAME <br /> OWNER ADDRESS /v �e CITY/STATE/ZIP L/�" 5e&-//0' <br /> CONTRACTOR / ��4 ,�QJ PHONE e / <br /> CONTRACTOR ADDDRE �� / �/ CITY/STATE/ZIP I� n.4 <br /> LICENSE IC'C-42 ❑f IC-36 OTHER NUMBERy7r-7z�-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 J REPAIR/ADDITION I I ENGINEER DESIGNE /ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: NK RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: / NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG /17 /— CAPACITY Z-Z a gal #OF COMPARTMENTS <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 /> LEACH LINES LEACHING CHAMBERS #of LINES J LENGTH OF LINES /L� GCc L'!� ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft ftPROPERTY LINE <br /> 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 77FOUNDATION ft PROPERTY LINE ft <br /> SUMPS WIDTH I ft LENGTH_ l y / ft DEPTH / ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION "t 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 URA VA CE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 95/3-7697 <br /> SIGNED Y TITLE GZ d1 y J� DATE —Al VAa <br /> f� r <br /> JUAt <br /> F Q <br /> H <br /> R <br /> P ARTMEN U E 0 Ah <br /> Application Accepted By to Area Employee ID# <br /> Final Inspection By Date 0 ❑ SPEC L PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> .S <br /> PE Sc Received hec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash lRemitted ervice Re uest# <br /> W <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />