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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 9g3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Q >T e H C CITY/ZIP Tea v „� 7 <br /> CROSS STREET 1z ;4 ����I �^h APN 2e,9 <br /> / — 3F2�2 aO PARCEL SIZE I . � <br /> OWNER NAME t v (� �" _ PHONE A <br /> J�(/ O�� ���J v, <br /> !� T <br /> OWNER ADDRESS / C v ,n yO� CITY/STATE/ZIPP7Y�j� ` <br /> CONTRACTOR \/ ('i S S �^l �'/ PHONE x7 z^ lla <br /> CONTRACTOR ADDRESS D ��^ �� 1A Q /,! e�� 3/b CITY/STATE/ZIP <br /> LICENSE P/C-42 ❑I_C-36 OTHER NUMBER 161 (/_3�U 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 REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL 11 OTHER <br /> NU <br /> MBERR OF LIVING UNITS: NUMBER OF BEDROOMS: 3 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 ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> a/LEACH LINES LEACHING CHAMBERS #OF LINES I LENGTH OF LINES / 4!�' 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 UOUR,4DVANCE NOTICE RE IRED FOR INSPECTIONS - PLEASE CALL 209)953-7697 <br /> -7 97 <br /> SIGNED TITLE ��n a DATE___!1 4t— <br /> NVR NIV EN TAL <br /> LT <br /> ARTMENT USE ONLY <br /> Application Accepted B A Date Area Employee ID# <br /> Final Inspection By Date zzdLWII SPECIAL PERMIT-Approved by <br /> Character of Soil to Dep of 3 Ft: Pit/Sump Soil CharaLer:_V <br /> COMMENTSI- <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code Z )INFO Cas Remitted Service Request/^# <br /> Q J!S� 3� r f7' ;11 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />