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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 r EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS J2 t 4 O�✓V CCITY�/ZIP <br /> CROSS STREET APN � (/YJy �-1 PARCEL SIZE <br /> c <br /> OWNER NAME C c' II a i✓1r ,���-r:�f PHONE ` v <br /> OWNER ADDRESS 1J�7� 7"f CITY/STATE/ZZIIP ��C,[<'1�✓�1 r� 5 ,�I <br /> CONTRACTOR 45 :GK �c/{_ PHONE <br /> CONTRACTOR ADDRESS 40e, )qC lX (. !� CITYISTATE/ZIPr <br /> LICENSE ❑CiC-42 ❑I'C-36 OTHER NUMBER EXPIRATION DATE (��D ,r1 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION## <br /> TYPE OF WORK: ! NEW INSTALLATION I REPAIR/ADDITION E EER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: 0 RESIDENCE ❑ COMMERCIAL 11 OTHER <br /> ,UIWBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG 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 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 /> ❑ 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 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 9�53-7+697 q <br /> SIGNED TITLE `-r7y) �! l ~U� DATE <br /> i <br /> N R N <br /> LLTIJ DPRMNT <br /> E P A R T M E N T SE N L Y <br /> Application Accepted B Date Area 4w Employee ID# 44 <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft:1 Pit/Srt p Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> 12- �2' S800811g6 <br /> 42-01 ONSITE WASTEWATE=R TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />