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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 CALL(209) 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS L 2 �-I ( j7H�� CITY/ZIP 'Stow'VX)N <br /> CROSS STREET <br /> G�n lfd Kc e APN0103 1 PARCEL SIZE <br /> OWNER NAME + LS7 G ,Z,y✓ - PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP Zoo,' (f,4 3 5 7 yo <br /> CONTRACTOR 5.4-e,-S;�o k y ��]'''�C" PHONE / /-- <br /> , <br /> CONTRACTOR ADDRESS / 9/0 -/ rN CITY/STATE/,ZIP /�'IyC/. �•�, j S'3Sr <br /> LICENSE 11r:C-42 111C-36 OTHER_ _ NUMBER?` S IJ3 EXPIRATION DATE_ <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 M REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> I i REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM M DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE I I COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFGCAPACITY J 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 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 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 4,40UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> /- PLEASE CALL 209 953-7697 <br /> SIGNED TITLE / &!GY DATE <br /> 16 O <br /> �N <br /> A T <br /> DEPARTMENTUSE ONLY <br /> Application Accepted By — Date Area Employee ID#�� <br /> Final Inspection By Date L01 f h 11 SPE AL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft:__-_ _ __ _ Pit/ ump Soil Ch racter: _ <br /> COkWENTS <br /> PE SC Receivedhec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B as Remitted Service Request#_ <br /> 417,0 Z/ALS — l�:L(_� T--- <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />