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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZEL'rON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT �J CALL(209)953-7697 FOR INSPECTIONS r EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS - -/ 75- S /' /ac ff rt-6 LJT -7 (�CITYIZIIP� �/t V r,4. q5--3 O�y <br /> CROSS STREET U I✓1 e APN G��j d 1 v CEJ PARCEL SIZE (D <br /> pr � d <br /> OWNER NAME �A)�y / 7CLE,vi�tZ PHONE Lyim/- 3c76-- 3733 r <br /> OWNER ADDRESS CITY/STATE/ZIP U <br /> CONTRACTOR r.4-L1«}D �r �'U/U- /VC. / PHONE ZO!2 <br /> CONTRACTOR ADDRESS �,2r CITY/STATE/ZIP <br /> LICENSE 111-IC-42 ❑PC-36 OTHER C NUMBER EXPIRATION DATEy,8 /000 a-CJ <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> r0 PERC TEST # -� BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION CI REPAIR/ADDITION DENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT CI OUT-OF-SERVICE SEPTIC SYSTEM X DESTRUCTION <br /> INSTALLATION WILL E: SIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY 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 C1 SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES I I LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER EKED WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINEt+�/�f� <br /> C MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ SUTAPS WIDTH ft LENGTH ft DEPTH yJOIQ ft' <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE O <br /> E3Mr.. <br /> DISPOSAL PONDS WIDTH It LENGTH ft DEPTH P 11 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE tT <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 HOURAVVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-76976 <br /> SIGNED TITLE G✓ice ) DATE Z::2 <br /> DO <br /> TIT <br /> EPARTMENT USE ONLY <br /> Application Accepted B Date Q Area mployee ID# <br /> Final Inspection By Date / ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: q' smp Soil Character: <br /> COMMENTS ,� a <br /> AA-rl - - <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO B ash Remitted Date Service Request# Invoice# Permit ID# <br /> `6,-, Z- t S <br /> 42-01 � G7 2GJ 1 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 ( J(7 I <br />