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`w <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 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS V, O CITY/ZIP l A �= <br /> a <br /> / y <br /> CROSS STREET —`� f APIN '�/ ...� i i� PARCEL SIZE p <br /> ') T� C i <br /> OWNER NAME a ��.u�x.r't I L4rr`y ��'y +- PHONE <br /> N <br /> OWNER ADDRESS/�� S 4yW� CITY/STATE/ZIP <br /> CONTRACTOR Y / l069t 5p/`�4C4Ol 6 �1/�':ts PHONE—aze'x— <br /> CONTRACTOR ADDRESS 'aC�( CITY/STATE/ZIP <br /> LICENSE I_' ;C-42 ❑F-C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # I FIBUILDING PERMIT# .. WS3AND USE APPLICATION# <br /> TYPE OF WORK: _ NEW INSTALLATION Cl REPAIR/ADDITION CI ENGINEER DESIGNED/ALTERNATIVE <br /> U REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM IJ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: �[J NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES:_ <br /> SEPTIC TANK TYPE/MFG N t CAPACITY gal #OF COMPARTMENTS_ <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATIONft PROPERTY LINE �U f _ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> -SACH LINES ❑ LEACHING CHAMBERS #OF LINE.., LENGTH OF LINES_ ft <br /> DISTANCE TO NEAREST WELL _ ft FOUNDATION ft PROPERTY LINF ft <br /> Ili FILTER BED WIDTH j01 ft LENGTH ��^1 ft DEPTH �g _ ft <br /> DISTANCE TO NEAREST WELLI C.)4+ ft FOUNDATION �•51 ft PROPERTY LINE �(b' 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 /> MINIMUM 48 HOUR44DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE C�Y�11�(�C'�(a�� DATE �� <br /> I9 <br /> O <br /> �D PARTMENT U.E (INLY <br /> Application Accepted By _ _ Dalf: Area Employee ID#e"Ok'-q/� <br /> Final Inspection By __ Date_ ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 t: _ Pit/Sump Soil Character: _ <br /> COMM�Kl�n At" <br /> A <br /> �_ fltr� <br /> PE SC Received he Amount Permit/ <br /> Code INFO By ash Fernitted Date Servicq Request# Invoice# Permit ID# <br /> .S <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />