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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 C S ! C_I< <br /> CITY/ZIP -y-,-y-, 5- T <br /> CROSS STREET �� APN(O3 AY" d PARCEL SIZE c <br /> 0 <br /> OWNER NAME ©LI v1 t�I �/r L-t'9/� �1� '`'�-' .�:��1-rl rl- C PHONE <br /> OWNER ADDRESS _�2Cii CITY/STATE/ZIP <br /> /�� '{�1 '�C ICS �Jn �'Y`hSI <br /> CONTRACTOR�1/ Y 1 I I�L�+��o � �'rLl�i 7y— �R�" PHONE L'{ 1 l <br /> CONTRACTOR ADDRESS !'1 °l'7\l ( O n CITY/STATE/ZIP MM, �n <br /> LICENSE ❑i IC-42 [11 C-36 OTHER NUMBER"T1� 7.5 q EXPIRATION DATE <br /> 1 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: L NEW INSTALLATION ENGINEER DESIGNED/ALTERNATIVE c <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM 14 DESTRUCTION <br /> INSTALLATION WILL SERVE: Lk RESIDENCE ❑ COMMERC AL �f� ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: !� NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG it� CAPACITY ��-?3-n-, gal #OF COMPARTMENTS_µ <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL 17 1 ft FOUNDATION SIS' ft PROPERTY LINE l ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> I <br /> LEACH LINES LEACHING CHAMBERS #OF LINES 3 LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 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 /> . 1 <br /> SEEPAGE PITS NUMBER WIDTH i ft DEPTH - � ft <br /> DISTANCE TO NEAREST WELL_ ALL ft FOUNDATION I r�, ft PROPERTY LINE 1,7) 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 HO,O,UWDVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL 209 953-7697 <br /> SIGNED TITLE ` ,4 -a,AgZ r DATE :') —7 1 <br /> Si11 107 <br /> OAQUI <br /> PAT ET <br /> DE ARTMEN UAE N Y <br /> Application Accepted By Date Area Employee ID# <br /> Final Inspection By Date © � 4119 ❑ SPE IA PERMIT-Approved by <br /> Character of Soil to Dept of 3 F . Pit/Sump Soil Character: <br /> YCIMMENTS O <br /> d <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO Cash emitted Date Service Request# Invoice# Permit ID# <br /> s b� sRoo� a 3 c� <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />