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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 �1M1� D�T CI�TYIZIP <br /> CROSS STREET 1 1 1 VT/ APN 1 1 O 11 1 5 PARCEL SIZE • J d <br /> Q (, <br /> b <br /> OWNER NAME <br /> not �•yV PHONE Sv ,— 2A --1 `-iV v <br /> OWNER ADDRESS 1 1_ / ��f/ CITY/STATE/ZIP J 11 -t j C 49452—IS <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑DC-42 ❑OC-36 OTHER NUMBER 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 O REPAIR/ADDITION ENGINEER DES] NE / LTERNA I E <br /> 0 REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION �Ci <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 /> ❑ 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 /> El FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> C3 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 /> �I 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 � Ift 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 48 HOUR ADVANCE NOTICE REQUIRED FOR IN PECTIONS - PLEASEXALL (209)1953-769 <br /> S I G NEW// // O YO "L(' TITL= W DAT <br /> QINC UN <br /> E14VI OqME_N AL <br /> 4T- <br /> EPARTMEN-TAJSE jbNLY <br /> Application AccAa Date Area Employee ID#� <br /> Final Inspection Dat ❑ SPECIAL PERMIT-Approved by <br /> I=Character of Sofi Pit/ u p Soil Chara er: <br /> MENTS l� r I <br /> o c6yws arl\ �AjA t� ski C 1 ry <br /> PE EINFO <br /> C Received ec #1 Amount Date Permit/ Invoice# Permit ID# <br /> Code B Cash emitted Service Re uest# <br /> � <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />