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1 , <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 PER/MIT 11 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 3 �/J7/e C T- CITY/ZIP O U <br /> CROSS STREET �Cf/I/''(or✓]C/ /�TJt�� APN_L�VJ�� 2— PARCELSIZE �• �� '' <br /> OWNER NAME «J 7�'�//1 r �///�/' PHONE m <br /> OWNER ADDRESS „ � p 1 6)^�A�YO�►-L (,/� CITY/STATE/ZIP <br /> CONTRACTOR C..1/1i�1' _/ l v >' 'Gf//� .�f'/!rJ' /6- PHONE -56- 27 <br /> a <br /> CONTRACTOR ADDRESS ?31 /S�'Y✓I` / -. CITY/STATE/ZIP <br /> LICENSE 1;116-42 El C-36 OTHER NUMBER O7 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 REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE I COMMERCIAL I I OTHER <br /> NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG 4-/"I 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 x LEACHING CHAMBERS �'7 C /�h .r� #OF LINES _ LENGTH OF LINES <br /> / <br /> DISTANCE TO NEAREST WELL SCD ft FOUNDATION l0O ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH jt <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ^ vD <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 4Jtln/ <br /> L3DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH AQ✓J/ <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE�LTI/or_ EIVA7k TM <br /> SEEPAGE PITS NUMBER WIDTH �� r/ ft DEPTH �NA�T"fC 7' <br /> ((( DISTANCE TO NEAREST WELL 15-0 r ft FOUNDATION /OO/ ft PROPERTY LINE 370 � ft <br /> I HEREBY CERTIFY THAT 1 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 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -/PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE 6�—60 / <br /> J <br /> DEPARTMENT SE/0 NLY <br /> Application Accepted B Date Area Employee ID# S�t� <br /> Final Inspection By Date 11 SP IAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pi <br /> is Soil Character: <br /> C MMENTS 7-5 L �- <br /> PE SC Received Check# Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash Remitted I Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />