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z <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 CRY/ZIP "�/� v' <br /> C '� j <br /> CROSS STREET ✓� J 17�r)U,n�� p I APN / PARCEL SIZE o <br /> OWNER NAME I V 919 N T ti/ �j 9 �� VPHONE-_CrM q/ �� <br /> ZoOWNER ADDRESS <br /> I ,�1 y� XII 9� TATE21P ('-SCC'1j017 <br /> , �1^'{(�, J <br /> CONTRACTOR l<'1 fe r'/�/���1/�&�f}�,, �//� C PHONE Lzo uI �7 i - ) µA7_s <br /> CONTRACTOR ADDRESS UJ�J/ "/ I/'1 11 I�Wr [q Ste- /60 CITY/STATE/ZIP S'hx-0" `1/ <br /> LICENSE ❑ C-42 ❑ C-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 REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE To NEAREST: WELL it FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH it DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE it <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTYLINE it <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH it <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTYLINE 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,HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697. <br /> SIGNED TITLE , DATE <br /> Arr <br /> jwj <br /> �Nr <br /> Eo <br /> 419 <br /> T <br /> C,V <br /> M NT <br /> i D ARTMEN IJ E O LY <br /> Application Accepted Dater---41444 Area Employee ID# <br /> Final Inspection By Date11�Zeilj ❑ SPE IAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: iUSump Soil Cha ra ter: <br /> COMMENTS a �Y� i <br /> p— k <br /> PE SC Received Check#/ Amount Permit] <br /> ode INFO B Cash Ftem,ttecl ate Service Request# Invoice# Permit ID# <br /> I S A-- Zq 0 <br /> 42-01 / �„G-p� -! I ! I ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />