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01 ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> 9AN 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 C i&j CITY/ZIP <br /> CROSS STREET /�, APN v V PARCEL SIZE <br /> ? r j <br /> OWNER NAME�)I-Ac [ FcJJA.,,u1E'A PHONE `1O6 <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR ���J��iGe[,. S(' 0/1//_ , PHONE :3(,95-6- z-7/ / <br /> CONTRACTOR ADDRESS '37"7�_ ` G'�i`CGi(J //����/ J� CITY/STATE/ZIP <br /> LICENSE []/5.-42 ❑❑C-36 OTHER NUMBER �5�90 5 EXPIRATION DATE U y/3>/Z/ <br /> 1 � <br /> WATER TABLE DEPTH: O ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I NEW INSTALLATION REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT f I OUT-OF-SERVICE SEPTIC SYSTEM I I DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE 11 COMMERCIAL 1-1 OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG Y Sr rU 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 /> LEACH LINES LEACHING CHAMBERS #OF LINES�_ LENGTH OF LINES yU ft <br /> DISTANCE TO NEAREST WELL ZCX).r ft FOUNDATION r ft PROPERTY LINE 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 10 ft DEPTH 49S i ft <br /> DISTANCE TO NEAREST WELL ZCO ft FOUNDATION /100 P A ft PROPERTY LINE A/5 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 Gcl9/ /C+ -- DATEIII All <br /> C <br /> 711 1 1 <br /> ti Q <br /> R <br /> T <br /> r EPARTMENT U E afNLY <br /> ff <br /> Application Accepted By Date 8 ZzArea Employee ID#� <br /> Final Inspection By Date I U I I N ❑ SPEC AL PERMIT-Approved by <br /> Character of Soil to Depth <br /> ��oftt3 Ft: Pit/Sump Soil Character: ����/,, <br /> CCOOMSMENTSft jg" , (,� 't l►-llAfC�J �(�O lidr /�V Azaw aly <br /> PE SC Received heck Amount D to Permit/ Invoice# Permit ID# <br /> Code INFO BV Remitted Service Re Uest# <br /> o 3 � �a S�o0gia \% <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />