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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 2'z J /S d �U L{—� ^p CITY/ZIP / d <br /> CROSS STREET o �fA <br /> APN / ` VO ( PARCEL SIZE .?. 7� <br /> 777 0 <br /> Ad& <br /> OWNER NAME `/ �1PHONE /�/► L►f CA <br /> OWNER ADDRESS L S CITYISTATE/ZIP ^ U <br /> CONTRACTOR ��/N//K C ����—, r �G`��r // PHONE `� J /J .3 I <br /> CONTRACTOR ADDRESS / /V I C�/V u l� y I� ' CITY/STATE/ZIP <br /> LICENSE I3 'C-42 D[-,C-36 OTHER A NUMBER?(S / S3 EXPIRATION DATE���i � <br /> WATER TABLE DEPTH:'Oy`� ft GEOGRAPHICAL INFORMATIO CO rdin es X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM i DESTRUCTION <br /> INSTALLATION WILL SERVE: #1 RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: l NUMBER OF BEDROOMS: ---LN NUMBER OF EMPLOYEES: <br /> 111 SEPTIC TANK TYPE/MFG CAPACITY / ZJJ gal #OF COMPARTMENTS Z <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL �� ,� ft FOUNDATION ft PROPERTY LINE S ' ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES S LEACHING CHAMBERS �� ? (. #OF LINES Z— LENGTH OF LINES P­n- ft <br /> DISTANCE TO NEAREST WELL �DJ` ft FOUNDATION ft PROPERTY LINE 5— 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 /> ❑ 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE f�/ <br /> Al <br /> T <br /> N <br /> -- <br /> DEPARTMENT O ALLY ��LL��� <br /> Application Accepted By Date Area Employee ID#A�V� <br /> Final Inspection By Date Q l ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 t: Pit/Sump Soil Character: <br /> COMMENTS <br /> % 60 z- -- _ G Its <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Coclk INFO By_ Remitted Service Request# <br /> 2l ( SROOS �a4a <br /> 42-01 ! F �!S��" SITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />