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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 C--AllLL^L,w, 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR[FROM DATE ISSUED <br /> JOB ADDRESS 7�'1�'" + CITYIZIP�/��G s4 q 5 577 r <br /> CROSS STREET 'AP 3 � e U V PARCEL SIZE <br /> OWNER NAME let A / 1A L 7 w 5herile.' PHONE <br /> T � <br /> OWNER ADDRESS —��ra—_ _ C ___-__ ___ —CITY/STATE/ZIP <br /> CONTRACTOR AC_- Sf)�(- CJC� ' PHONE <br /> CONTRACTOR ADDRESS _lyU C _ o_ QIs✓)v �✓ C� CITY/STATE/ZIP <br /> LICENSE LIIIC-42 ❑1'C-36 OTHER_ NUMBER ! �3 EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I NEW INSTALLATION NP REPAIRIADDITION CI ENGINEER DESIGNED/ALTERNATIVE <br /> I_' REPLACEMENT LI OUT-OF-SERVICE SEPTIC SYSTEM jV DESTRUCTION ! j aoy A <br /> INSTALLATION WILL SERVE: 19 RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER/OF BEDROOMS: -7 NUMBER OF EMPLOYEES: 7 <br /> A9 SEPTIC TANK TYPE/MFG F. CAPACITY �o 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 1 l 'LEACHING CHAMBERS #OF LINES l LENGTH OF LINES 7 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 /> m SUMPS WIDTH �L 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 /> 1 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 44 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE <br /> T <br /> Abu <br /> At <br /> I FM <br /> O <br /> T <br /> EPARTMENT SE ONLY <br /> Application Accepted By Date Area ZA4 Employee ID#�� <br /> Final Inspection By Date ❑ SPE IAL PERMI -Approved by AMAZ <br /> Character of Soil to pt3 Ft: Pit/Sump Soil Character: <br /> CO MENTS <br /> r -'L-7 l sw <br /> d c - 6C <br /> PE SC Received Chec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By as Remitted Service Request# <br /> z/oS 606-12-S <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />