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r <br /> t <br /> 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 /^(r CALL(209)((953-7697 FOR INSPECTIONS p _EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS fi � h (��rrJ L4l< 1t�C CITY/ZIP <br /> CROSS STREET IP.1 L APN PARCEL SIZE T��r b 3 <br /> 0 <br /> OWNER NAME `� I.�.$�J }0-.J PHONE <br /> OWNER ADDRESS t`AG t CITY/STATE/ZIP S.���}o-1 <br /> CONTRACTOR I_ �'h � u � PHONE 'EDS ef i l-� Z I I <br /> CONTRACTOR ADDRESS n CITY/STATE/ZIP <br /> LICENSE ❑ C-42 ❑[:C-36 OTHER(7Wrer hc�.��QRr NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# P- I OK"V( LAND USE APPLICATION# jiO <br /> TYPE OF WORK: X: NEW INSTALLATION I REPAIR/ADDITION ENGINEER DES,&W/ALTE AIV Q <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION �/� J <br /> INSTALLATION WILL SERVE: RESIDENCE I I COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: A�T <br /> C& SEPTIC TANK TYPE/MFG CO 4}e- CAPACITY I'p0© gal #OF COMPARTMENTS ;z <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 J LENGTH OF LINES Ao 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 /> U SEEPAGE PITS NUMBER 3 WIDTH " ft DEPTH -2` ft <br /> DISTANCE TO NEAREST WELL 4 ft FOUNDATION iV 50 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 /> S=ELAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> INIM 4 HO VOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 953-7697 <br /> SIGNE TITLE dDATE -3 t <br /> la <br /> 44 1 <br /> Z <br /> I <br /> A <br /> ' DEPARTMENT US E 0 NLY <br /> Application Accepted By Date Area Employee ID# <br /> VohwFinal Inspection By Date $PE IAL PERMIT-Approved by <br /> Character of Soil to 1) of 3 Ft: PiUSump Soil Character: <br /> COMMENTS •c_ ea <br /> PE Sc Received he Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Remitted Service Request# <br /> 74 It2rLSopu <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />