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r � <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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 45CITY/ZIP Z Z L <br /> / m <br /> � S/yam Z b <br /> CROSS STREET /��/� a/V APN PARCEL SIZE y <br /> 0 <br /> 0 <br /> OWNER NAME G/� ll (/(�l�- PHONE V606 9 „92 v <br /> OWNER ADDRESSr� CITY/STATE/ZIP <br /> CONTRACTOR A mle4A k S<OhC_ .1 G''�^ PHONE <br /> CONTRACTOR ADDRESS / `/ / /-`k,* (/.�Cx­,� !/ - t� CITY/STATE/ZIP ,A,,✓` <br /> LICENSE ❑LIC-42 ❑LIC-36 OTHER NUMBER / 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 of REPAIR/ADDITION _ ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: rl RESIDENCE I I 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 /> ❑ LEACH LINES d LEACHING CHAMBERS Z / #OF LINES LENGTH OF LINES r) 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 It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> Yd SEEPAGE PITS NUMBER "Lam- WIDTH '7 ft DEPTH Z r' ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION �� ft PROPERTY LINE J^ - 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE ri►�� DATE ' '2 <br /> T <br /> D <br /> 9 <br /> L__ IJUIA11-C 7Y <br /> D p <br /> T <br /> D EPA R TM EN TIJSE ONLY <br /> Application Accepted By Date Area ployee ID# _ <br /> Final Inspection By Date ❑ SP �ALPERMIT-Approved by <br /> Character of Soil to Depth of i Ft: I PAsump Soil Character• <br /> COMMENT Z <br /> PE SC ReceivedCheck Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash Remitted Service Request# <br /> 'Z 0 / lAy <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />