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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 P MIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP <br /> CROSS STREET V(� /t APN�',K z2w '�f�,� PARCEL SIZE <br /> OWNER NAME Lf v Vr�D/��/�\- - �, JG�C�S{� PHONES <br /> Y <br /> OWNER ADDRESS I�U Vl CX�/� !/`' r+ CITY/STATE/ZIP f';/��/""lJ� <br /> CONTRACTOR C"V-t rA V"W� ��/1 VG/V��- PHONE � SIV t6`L <br /> CONTRACTOR ADDRESS -CITY/STATE/ZIP <br /> LICENSE 111-IC-42 ❑CTC-36 OTHER L NUMBER V h 4 EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: F NEW INSTALLATION CI REPAIR/ADDITION CI ENGINEER DESIGNED/ALT ATI E <br /> LI REPLACEMENT 11 OUT-OF-SERVICE SEPTIC SYSTEM 9 DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG -flCAPACITY 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 i LINES C1 LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> G 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 /> MINIMJJM 48 UR AD NCE NOTICE REQUIRED FOR IN ECTIONS - PLEASE CALL 209 9 3-769 <br /> SIGNED -IrTITLE DATE <br /> Lilliw <br /> A U114 C OU 01 <br /> N FIRT N <br /> H <br /> I I LL/ 1 Li <br /> EPA RTME SE z <br /> - <br /> Application Accepted B Date Area 4? <br /> Employee ID <br /> "qkFinal Inspection By Date ❑ SPEC AL PERMIT-Approved by <br /> Character of Soil to Depth of 3 F : Pit/Sump Soil Cha acter: r <br /> COMMENTS P�'i�i�,� �i- 3 V 2 D-tf K-5�. S <br /> Mg rewVve-j <br /> PE SC Received Check#/ Amount D e Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Re uest# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />