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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 a CITY/ZIP; 'fi-,aeAn ,c, v <br /> CROSS STREET Li'LL_ APN [Z3 i;) C] 7.L PARCEL SIZE p <br /> v <br /> OWNER NAME( G'y.M Sln'y 'YV1 PHONE l <br /> OWNER ADDRESS,/J._ �C✓S.t� CITY/STATE/ZIP Sfiac-k 1-v <br /> CONTRACTOR k4 11 �4� 0) PHONE__ n^ <br /> CONTRACTOR ADDRESS A) Acy CITY/STATE/ZIP �'► !C'.��`�1.� ICr'I` �� 3�� <br /> LICENSE ❑CIC-42 ❑r:C-36 OTHER YJ NUMBER `(/��J` —I 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 0 REPAIWADDITION 1 I ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT 1-1 OUT-OF-SERVICE SEPTIC SYSTEM I I DESTRUCTION <br /> INSTALLATION WILL SERVE: i RESIDENCE ❑ COMMERCIAL11 OTHER <br /> NUMBER OF LIVING UNITS: I 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 /> k LEACH LINES -1 LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> ft <br /> DISTANCE TO NEAREST WELL ? ft FOUNDATION ' ft PROPERTY LINED ft <br /> P- FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 2 MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> Q 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 /> lJ' SEEPAGE PITS NUMBER d\1 WIDTH 31>`/ ft DEPTH S I ft <br /> DISTANCE TO NEAREST WELL L_a�_ ft FOUNDATION ft PROPERTY LINE j" 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 HCLUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE �71'��c t='7 DATE .3 G # <br /> kcaw 1111L <br /> El VI O M N <br /> H EAT D P T ENT <br /> VA kEIPA R TM EN T SENLY <br /> Application Accepted B Date Area Employee ID# <br /> Final Inspection By Ay Date gun ❑ SPEC AL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: _ Pit/Surnp Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO B Cash emitted Date Service Request# Invoice# Permit ID# <br /> o I a 0 7 <br /> 42-01C� � .{. �J J� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 �(fL r �P / v <br />