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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 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP J y <br /> CROSS STREETI?A-n 4/ 1 APN I w q D PARCEL SIZE <br /> OWNER NAME y AA/Fi PHONE _'<y/ �n <br /> OWNER ADDRESS G LAI CITY/STATE/ZIP v <br /> CONTRACTOR J` t Q . PHONE '2-10:g <br /> i <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑' 'C-42 F-11,C-36 OTHER A NUMBER O EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: LI NEW INSTALLATION REPAIR/ADDITION f-1 ENGINEER DESIGNED/ALTERNATIVE <br /> U REPLACEMENT I ' OUT-OF-SERVICE SEPTIC SYSTEM LI DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> _17— <br /> El GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ?(/ , ft FOUNDATION � ft PROPERTY LINE S� ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> Jay LEACH LINES 1-1 LEACHING CHAMBERS #OF LINES LENGTH OF LINES !L/"X <br /> ft <br /> 17 ,�7 <br /> DISTANCE TO NEAREST WELL_ ft FOUNDATION ylJy 42 ft PROPERTY LINE S 4L ft <br /> ❑ FILTER FEED 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 NEARES WELL ft FOUyN�DATION ft PROPERTY LINE ft <br /> 2 <br /> GT � <br /> SUMPS WIDTH ft LEN ,1 ft DEPTH 9j ft <br /> DISTANCE TO NEAREST WELL 1. ft FOUNDATION b/1" ft PROPERTY LINE ✓ y 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 /> MINI 48 H0YejnQVANPE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE lam' // DATE <br /> /N <br /> p F h <br /> 9 PA R TMEN TAJSE (INLY <br /> Application Accepted By Date Area Employee ID# <br /> Final Inspection By�� 1 �� i�—tr Date ® �7 11SV� P IAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS - !tel d� <br /> /2o e <br /> opo o� s _ —Sk Bl9 <br /> PE SC Received Chec Amount Permit/ <br /> Code INFO B Cash Remitted Date Service Request# Invoice# Permit ID## <br /> 11-S LA -4111oz- <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4114/18 <br />