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J - 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 ZOO SCA n n U! CITY/ZIP Com` O � <br /> =l <br /> CROSS STREET �!/l1?;r'11/ � APN -^!�O �� PARCEL SIZE <br /> OWNER NAME 1'� LU PHONE / ] �i <br /> � rA <br /> OWNER ADDRESS _ 5A*16- CITY/STATE/ZIP <br /> CONTRACTOR 1' ��IVL,�� �/ L� rn��t�� L PHONE <br /> CONTRACTOR ADDRESS L ZJJ�Z (.S{�W7(, VI r 1�/t` CITY/STATE/ZIP <br /> LICENSE ❑IJC-42 El 74-36 OTHER NUMBER )16 3�Z� EXPIRATION DATE Z(/ <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: L NEW INSTALLATION O REPAIR/ADDITION LI ENGINEER DESIG D/ALTERNATIV <br /> I..! REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ &HER <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 /> f� LEACH LINES F, LEACHING CHAMBERS #OF LINES LENGTH OF LINES 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 /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY T AT I HAVE PREPED 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 /> NIM 48 AURA V NCE NOTICE REQUIRED FOR IN PECTIONS- PLEASE CALL 209 -7697 <br /> SIGNED TITLE UCI��f DAY Z7 Q -LS'( /q <br /> 70 <br /> INN <br /> NIR N TAX <br /> D&CARTMENT S NLY <br /> Application Accepted By Date Area Employee ID/I <br /> Final Inspection By _ Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 t: __ Pit/Sump Soil Character: <br /> COMMENTS i — g1c �,,.,,.l� Jai �uC -- <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO B Cash Remitted Dapt�e Service Re uest# Invoice# Permit ID# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />