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.0 ' ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> S}N JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 2O9 953-7697 FOR INSPECTIONS EXPIRES 1-YEARFROMDATE ISSUED <br /> JOB ADDRESS CITY/ZIP / > / &2,) 7 <br /> j <br /> CROSS STREET / APN (�� I � PARCEL SIZE <br /> OWNER NAME ! n PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR�/ G`^ t'.�G ' PHONE J/( <br /> CONTRACTOR ADDRESS /z2!�."' ��_riflL � CITY/STATE/ZIP <br /> LICENSE ❑I C-42 ❑I C-36 OTHER � NUMBER S d'0� EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I 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 /> (3 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 Grt TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 1/ <br /> /0 LEACH LINES LEACHING CHAMBERS J #OF LINES 2- LENGTH OF LINES 4/0 J ft <br /> DISTANCE TO NEAREST WELL / 0a /4- ft FOUNDATION //7 )-) 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 NE ARE T WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ld-�SEEPAGE PITS NUMBER WIDTH ft DEPTH L�zj_/ ft <br /> DISTANCE TO NEAREST WELL �5'0 - ft FOUNDATION _z/J j�ft PROPERTY LINE _9L 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 /> MINIA&a48 HOUR AVIVANCeNOTIPE REQUIRED FOR INSPECTIONS - PLEASE CALL L209)9Q-7697 <br /> SIGNED TITLE �.0 DATE <br /> NT <br /> so <br /> FD <br /> 19 <br /> tzNIlZfVO NTY <br /> F <br /> NT <br /> DEPARTMENT USE OI LY �+ ,r <br /> Application Accepted By Date Area Employee ID# .� <br /> Final Inspection By DateSPEC AL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: it/Sump Soil Character: <br /> C MENTS <br /> � S t <br /> PE SC Received ec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash Remitted Service Re uest# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />