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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 V L L ^CITY/ZIP � �J 3 O L, <br /> CROSS STREET C�/iCi// �� APN Z �� 3� –1 PARCEL SIZE g <br /> OWNER NAME I/��� &Acei6L II�'r PHONE 41 <br /> v: <br /> OWNER ADDRESSOr/V- CITY/STATE/ZIP ��Q,(n (���i/► �^�Sr3 O y <br /> CONTRACTOR D//J iC c coo JL-c �"��� PHONE Q � <br /> 11 <br /> CONTRACTOR ADDRESS //( �! 7V �/- V► {'`'�� CITY/STATE/ZIP �C/ _ 11?j i <br /> LICENSE ❑f IC-42 [IF C-36 OTHER NUMBER!�7�� 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 REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE <br /> I REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I i DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ 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 ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> X <br /> LEACH LINES I LEACHING CHAMBERS #OF LINESy LENGTH OF LINES In n ft <br /> DISTANCE To NEAREST WELL ft �FOUNDATION `b 1'�_ ft PROPERTY LINE 1 ' ft <br /> WIDTH 4 — ft LENGTH ft DEPTH —1— ft <br /> DISTANCE TO NEAREST WELL FOUN ATION 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 N TI E REQUIRED FOR INSPECTIONS,,C� - PLEASE ALL 2 953-7697 <br /> SIGNED TITLE 6DAA'9(: 0,1' DATE All <br /> NT <br /> ED <br /> 019 <br /> E -COUNTY <br /> IEALTR D AL <br /> P T ENT <br /> RTMENT USE ONLY <br /> Application Accepted By Date r <br /> -:? —19 Area Employee ID# <br /> Final Inspection By DatezAt ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS O o <br /> PE Sc Received Chec Amount Permit/ <br /> Code INFO By emitted Date Service Re uest# Invoice# Permit ID# <br /> "I L_-7 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />