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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 CITY/ZIP J�/ CI4]919 - <br /> CROSSSTREET A P N (✓40N_--:0 ` `�� "' C/ PARCEL SIZE A <br /> �y b <br /> OWNER NAME (/ /i�.l/J' / /� �✓ 17( _ �fOU� _ <br /> 6�=� e"' �/ qac' PHONE ! �/y K, <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR X'6 4�rl� "7✓j {/��GC i PHONE q:5 <br /> s <br /> CONTRACTOR ADDRESS � ? /no�Y �6 CITY/STATE/ZIP ] � �J✓(/ !� 54-z�v' <br /> LICENSE 111.IC-42 1111C-36 OTHER /"/ NUMBER d EXPIRATION DATE <br /> WATER TABLE DEPTH:7o -, u ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ R PAIR/ADDITION L I ENGINEER DESIGNED/ALTERNATIVE <br /> U REPLACEMENT I.1 OUT-OF-SERVICE SEPTIC SYSTEM 0 DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAJ� El OTHER <br /> NUMBER OF LIVING UNITS: �J JNUMBER OF BEDROOMS: �G NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG / CAPACITY r7 gal #OF COMPARTMENTS <br /> D GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELLft FOUNDATION �' ft PROPERTY LINE ��-t ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP_ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES 1-I LEACHING CHAMBERS #OF LINES _ LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL lU/J ,� ft FOUNDATION 117 ft PROPERTY LINE f ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It <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 J,ft FOUNDATION ft PROPERTY LINE ft <br /> x SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> � 3 <br /> DISTANCE TO NEAREST WELL_/ ft FOUNDATION �J� l 4. 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 /> MINhWJM 48 HOURADVAMCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGN TITLE r'i 0 DATE�/b _2 <br /> T <br /> D <br /> 0 NV 9 <br /> J <br /> R C U 1Y <br /> D p A( <br /> DE 4ARTMWSE/O T <br /> Application Accepted By - DateArea Employee ID#Final Inspection By Date ❑ SPE IAL PERMIT-Approved by <br /> Character of Soil to Dept i of 3Ft: Character: <br /> COMMENTS� � ! J,�/ jl(�� �/p �iyJ< </ f� <br /> ST� T <br /> PE SC Received (Check#D Amount Permit/ <br /> Code INFO B ash Remitted Date Service Request# Invoice# Permit ID# <br /> /9 5&008 i as <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />