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c <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 FORINSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS -c-, j, 4le CITY/ZIP �' <3C ✓� G✓F �' <br /> CROSS STREET rI Sa tVJ AP 0 ZZ ' 0 PARCEL SIZE c <br /> OWNER NAME LZ� r ��.���1 ��r 1-'�`1't- y � i j PHONE U �r��(a}' m <br /> v <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR, IL{IS c �'�>✓ �. PHONE �1 <br /> CONTRACTOR ADDRESS T �I�C O CITY/STATE/ZIP <br /> LICENSE ❑ C-42 ❑''C-36 OTHER NUMBER TS 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: ESIDENCE ( I COMMERCI I I OTHER <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 /> LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES y(�f ft <br /> DISTANCE TO NEAREST WELL ? ft FOUNDATION ft PROPERTY LINE 1 O 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 /> il' SEEPAGE PITS NUMBER WIDTH y ft DEPTH ft <br /> ft <br /> DISTANCE TO NEAREST WELL I SO I ft FOUNDATION ! ft PROPERTY LINE td 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 HOUg ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE_- DATE <br /> i� <br /> O <br /> T <br /> N <br /> F <br /> DEPARTMENT USEAONLY <br /> Application Accepted By Date it 1,0 Area Employee ID#ISly � <br /> Final Inspection By Date Ity <br /> ❑ SP IAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PiUSump it Character: <br /> COM ENTS � '3 <br /> er I A-) r ak—�-Lr -i J <br /> PE SC Received Check Amount Permit/Code INFO B ash Remitted Date Service Request# Invoice# Permit ID# <br /> S <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />