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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 C CALL(209)953-7697 FOR INSPECTIONS �+ EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I? S �; � �D CITY/ZIP �T '� G yl� U <br /> CROSS STREET ft am I^��� � APN Z /� � OO — ` O PARCEL SIZE (i . <br /> OWNER NAME 4, et d t 6C•sr 1 F ,b J <br /> PHONE � <br /> 3zZ�'l s �11�'�,f /= Q U <br /> OWNER ADDRESS b[If� � CITY/STATE/ZIP 1� t�1LV � n J <br /> CONTRACTOR�/ 1 IL2�/� ��d'(.1� ' 3 c +i/i C%2i PHONE7�� <br /> CONTRACTOR ADDRESS l i) r Cis.S CITY/STATE/ZIP . C%���c ��.✓�" /.� ��n <br /> LICENSE 11! IC-42 ❑I C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH:1�OkA"(A ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> v <br /> ❑ PERC TEST # F BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I ,IJEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> V/ REPLACEMENT Tcm IL OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: ESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG 'tT� CAPACITY j jj� gal #OF COMPARTMENTS **)- <br /> [3 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 /> U FILTER BED WIDTH 1 C) ' ft LENGTH 14,, ft DEPTH ) 43 i ft <br /> DISTANCE TO NEAREST WELL )Or)' ft FOUNDATION _��� ft PROPERTY LINE_ S / ft <br /> ❑ MOUNDED WIDTH ft LENGTH It 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 HPUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS// - PLEASE ALL (209)953-7697 <br /> SIGNED TITLE `.01,'14'C4. EC, DATE `^ 'In. 1 <br /> PAI filt�N' <br /> INFE <br /> J <br /> D P111E1 <br /> 1APARTMENI UISEO L <br /> Application Accepted Date Area Employee ID# <br /> Final Inspection By L{/U kA Date ❑ SPEC L PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Plt/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received ec Amount Permit/ <br /> Code INFO B ash emitted D to Service Request# Invoice# Permit ID# <br /> 2 ut> , 5 ,E6a/OS <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />