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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 t:1EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP SC:JL1 <br /> CROSS STREET Gam.,i 1 APN -7-0 C 7 L PARCEL SIZE •i c <br /> O <br /> )) �� A <br /> OWNER NAME �= J• ✓i � `-1 <br /> PHONE 7!) — <br /> OWNER ADDRESS ��i V� \"Zr� It•,7 CITY/STATE/ZIP It-fi- <br /> '/ I r <br /> CONTRACTOR.` r/��1 L-cS A 4..),e— PHONE 14 T, XGis` <br /> CONTRACTOR ADDRESSFf��jnX �' S J CITY/STATE/ZIP 4b--2j1--c,4 I Cr+ 95 3j L-z <br /> LICENSE El C-42 E) C-36 OTHER NUMBER �" - EXPIRATION DATE � •z, <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: I RESIDENCE COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: c7< //\\ 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 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 ��J ft <br /> DISTANCE TO NEAREST WELL11b ft FOUNDATION (6 ft PROPERTY LINE <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 HOU Al2VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED 1 TITLE e!: {I f- DATE <br /> Nr <br /> FD <br /> 0 19 <br /> N O771 <br /> Nry <br /> A <br /> T <br /> DEPARTMENT Ll SE 0 N L Y <br /> Application Accepted By Date ` Area VEmployee ID# � <br /> Final Inspection By Date C3 � S CIAL PERMIT-Approved by <br /> Character of Soil to Depth{ef Ft: Pi Sump Soil Character: <br /> COMMENTS rf t ,I t':;z. <br /> S <br /> PE SC Received 1---Ch!qW Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Remitted Service Request# <br /> hi,11 W7 <br /> 01 U 5 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />