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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 c CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM sDATE ISSUED <br /> JOB ADDRESS �+ L v CITY/ZIP <br /> CROSS STREET APN 77'7C_9 3 PARCEL SIZE -1f7A,_ <br /> C_' <br /> OWNER NAME —�►iS�fL�+=-+���C---Ji S IrLa PHONE <br /> ,I J c y J <br /> OWNER ADDRESS *2(Cggy j.I 0,24f CITY/STATE/ZIP <br /> CONTRACTOR ' 71 �m ��G[/�/� PHONE �J^��S� 7��3 <br /> CONTRACTOR ADDRESS/`1 ` ��//��C��+`� �!� CITY/STATE/ZIP '/j • <br /> LICENSE DDC-42 I-11IC-36 OTHER-0iNUMBER `� EXPIRATION DATE <br /> WATER TABLE DEPTH:L('V % ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# T <br /> TYPE OF WORK: LI NEW INSTALLATION V REPAIR/ADDITION I i ENGINEER DESIGNED/ALTE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I I DESTRUCTIONQcn <br /> INSTALLATION WILL SERVE: 00 RESIDENCE IJ COMMERCIAL I_ OTHER <br /> ZAIV <br /> NUMBER OF LIVING UNITS: ( NUMBER OF BEDROOMS: NUMBER OF EMPLOYEE,,',' 771••0Q <br /> ❑ SEPTIC TANK TYPE/MFG 1041 .'! �T? CAPACITY gal #OF COMPARIT§%Ty EP <br /> ❑ GREASE TRAP TYPE/MFG / CAPACITY gal #OF COMPARTMENTS T <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 /> ® FILTER BED WIDTH /S ft LENGTH j' ` ft DEPTH ft <br /> DISTANCE TO NEAREST WELL f ft FOUNDATION Sic) ft PROPERTY LINE S 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 hiOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE D <br /> ii6c. `Y <br /> PARTMEN E O LY <br /> Application Accepted By Dat-AV_z_1WfiqArea Employee ID# <br /> dwi*14 <br /> Final Inspection By Date f__l SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> _peewtj OA/ <br /> PE SC Received Che Amount Date Penult/ Invoice# Permit 1D# <br /> Code INFO BV Cash Remitted GService Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />