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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 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS w O CITY/ZIP �� v' <br /> ..`` <br /> CROSS STREET ! APN� 7� U / PARCEL SIZE <br /> OWNER NAME Vy A A/ PHONE 7 /- 1?y <br /> OWNER ADDRESS CITY/STATE/ZIP / <br /> CONTRACTOR Ad6,4 A 1 �r� C = Sem a,-- PHONE E--7 JT___ <br /> T^ 6, �_3 <br /> ` J <br /> CONTRACTOR ADDRESS 7 c'GI ���/y tj,, cto d, CITY/STATE/ZIP <br /> LICENSE 01 C-42 11C-36 OTHER NUMBER-715"," EXPIRATION DATE <br /> A �- <br /> WATER TABLE DEPTH:`/� �10 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION K REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION <br /> INSTALLATION WILL SERVE: ILII RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NU <br /> MBERER 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 ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES -V LEACHING CHAMBERS L w #OF LINES LENGTH OF LINES y ft <br /> DISTANCE TO NEAREST WELL .�'-':) ft FOUNDATION 3.� ft PROPERTY LINE o ' 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 `;t' ft LENGTH z ft DEPTH ,z © ft <br /> DISTANCE TO NEAREST WELL /,51)' 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 It FOUNDATION ft PROPERTY LINE ft <br /> 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 RE IR D FOR INP TI N - PLEASE CALL 202)953-7697 <br /> SIGNED �`— TITLE DATE T' <br /> WIG <br /> AA V11 A NO N <br /> E � <br /> EPARTME SE N Y <br /> Application Accepted B _ Date If Area Employee ID# <br /> Final Inspection By Date . ❑ SPECI L PERMIT-Approved by <br /> Character of Soil to pth t: Pit/Sump Soil Character: <br /> COMMENTS-t1-jSf.,3 , .1 W 4r,017&&Zde <br /> Co <br /> PE SC Received heck Amount Perm t/ <br /> Code INFO B emitted Date Service Request# Invoice# Permit ID# Li <br /> oi � -15 t <br /> OIL <br /> Ili <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />