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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> y 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 I l 4( Vin /J CITY/ZIPr,-S L*gn�, !Y�' � <br /> CROSS STREET i��n_ _f f� APN - 10 PARCEL SIZE > <br /> d <br /> C^ ^ Q ,[ r 'T �a v <br /> OWNER NAME- �y,Y�F rW` / �V c �"Ai G 't/� �q d PHONE y <br /> f^ � <br /> OWNER ADDRESS �����( 464 r�- r CITY/STATE/ZIP.t5'5C---.6 N (L� 9• �� <br /> CONTRACTOR V'f\jL--G� nn 4e-Arll 3Z+ ( PHONE1`1f� <br /> CONTRACTOR ADDRESS TZ� (�S�> CITY/STATE/ZIP �1c•�1 A-41'c 04 16v+ <br /> LICENSE 01-IC-42 ❑CIC-36 OTHER A NUMBER f, 74 EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# O LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION FI REPAIR/ADDITION EI ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT IJ OUT-OF-SERVICE SEPTIC SYSTEM U DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: LI / NUMBER OF EMPLOYEES: <br /> C�+ASEPTIC TANK TYPE/MFG 'w Pk), CAPACITY _i�J ZS� gal #OF COMPARTMENTS _ <br /> <❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL (a6r ft FOUNDATION ft PROPERTY LINE (( ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> Li' LEACH LINES 1-1 LEACHING CHAMBERS #OF LINES LENGTH OF LINES G t ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 1�'�)J" ft <br /> ❑ FILTER BED 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 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 /> H <br /> SEEPAGE PITS NUMBER WIDTH 3c,(( ft DEPTHa--':�, ft <br /> DISTANCE TO NEAREST WELL 1 5Zj ft FOUNDATION �CSt ft PROPERTY LINE ft <br /> 1 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 HQUa ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE <br /> T <br /> E /N <br /> E T <br /> N <br /> :ePARTMENTVSFIONLY <br /> Application Accepte By Date-� Area Employee ID# /� <br /> Final Inspection By Date SPEC AL PERMIT-Appr9 ved by <br /> Character of Soil to Depth of 3 Ft: C1.1�i1����M Pit/Sump Soil Character: � �, SAO / <br /> COMMENTS �i (���lll�J_ <br /> t>Z - - sir <br /> PE SC Received ec IFAmountermit/ <br /> Code INFO B sh emitted Date ervice Request# Invoice# Permit ID# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4114/16 <br />