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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 1YEEAR FROM DATE BSSUED <br /> JOB ADDRESS Al C..fi Aez 12oral CITY/ZIP <br /> CROSS STREET _-Zai/7 o va APN D o (�D o PARCEL SIZE tz <br /> Y <br /> OWNER NAME I 2-Z-e- Ue PHONE PO g? 7�S /- <br /> OWNER ADDRESS f L �/ / CITYISTATE/ZIP C� Q �J <br /> CONTRACTOR (.�E✓IT✓L)/ /{Y_C�l4l ��C PHONE �G I /_, Q ( -/���Q/ <br /> CONTRACTOR ADDRESS P 31� ©l so., 0,-- <br /> CITY/STATEIZIP & ' <br /> LICENSE ❑CX-42 ❑0C-36 OTHER NUMBER Y51�015_ --?/EXPIRATION DATE ?- � <br /> WATER TABLE <br /> DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: U NEW INSTALLATION REPAIR/ADDITION U ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: � ) NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG 4�1 r�11►9�f CAPACITY gal #OF COMPARTMENTS <br /> U 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 /> XLEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES 7 C� f ft <br /> DISTANCE TO NEAREST WELL /©O or ft FOUNDATION 175 ft PROPERTY LINE SO , ft <br /> U 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 /> 4f SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL 0 ft FOUNDATION �fS J ft PROPERTY LINE �rO 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 ` 0HOUR ADVANCEWOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE <br /> VE6 <br /> J <br /> 2019 <br /> P Tq� <br /> MENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date ,— © Area "( Employee ID# <br /> Final Inspection By Date P61 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to DD t of 3 Ft: it/Sump Soil Character: <br /> COMM NTS i"�`YIry <br /> V✓L q— o -s <br /> PE SC Received ChAmount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ec Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />