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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 2119 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 2127 CITY/ZIP S <br /> m <br /> CROSS STREET - APN 1741cyo PARCEL SIZE <br /> Zi O <br /> c 4t <br /> OWNER NAME rL a .`7' PHONE <br /> OWNER ADDRESS 3�(^�-�,--! �+��� C�0.01�-A /i J CITY/STATE/ZIP 5lpi.Gf�T�(�J-'� cJ`- b4 <br /> CONTRACTOR GSW l7CVl� (/llll CN Y`Xzl7L PHONE /�rl~i�/L1�J 3(-c1 <br /> - SO 2 <br /> CONTRACTOR ADDRESS _ /��_ (.%J7Zft.C'w %�ji�C P� —CITY/STATE/ZIP </Ys�1C6z� ' -1 <br /> LICENSE ❑A-42 L11-IC-36 OTHER NUMBERS�J � EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION#1 <br /> TYPE OF WORK: NEW INSTALLATION! + REPAIR/ADDITION ENGINEER DESIGN pIALTERNATIVE <br /> �. REPLACEMENT /) 1-lk OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: (RESIDENCE C COMMERCIAL C OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG 7L fl CAPACITY 1,)64> gal #OF COMPARTMENTS <br /> E3GREASE TRAP TYPE/MFG 1 CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION Ic" 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 LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 /> LY <br /> AUI CU <br /> ENVIRONMENTAL <br /> DEPARTMENT USEONLY <br /> Application Accepted By Date 1 Area /--"Employee ID# <br /> Final Inspection By \ Date 2 k4 4 G SP IAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/SU S it arac r: <br /> COMMENTS f— z der G` <br /> Ute/ Pt <br /> W9,o aid Ha 'bn ,�� 16f , <br /> PE SC Receivedi, Check / Amount D to Permit/ Invoice# Permit ID# <br /> Code INFO Bv Cash Remitted Service Request# <br /> 1 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />