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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 EXPIR <br /> E <br /> S 'I YEAR FROM DATE ISSUED <br /> JOB ADDRESS V CITY/ZIP <br /> CROSS STREET 6�N APNo�?L7a - 6 v PARCEL SIZE V F <br /> OWNER NAME !(y ��/C dLzY zzo PHONE -3:S/- -3/d <br /> OWNERADDRESS°b° CITY/STATE/ZIP <br /> CONTRACTOR - <br /> �/�is PHONE 11-6'C'-S U?'7 <br /> CONTRACTOR ADDRESS >Z_ v!/V -��u �1�7i/` / I�t,� CITY/STATE/ZIP <br /> LICENSE 42 J 1C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: I O, (I ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: C NEW INSTALLATION �K,REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE 1_1 COMMERCIALgg IJ OTHER <br /> NU <br /> MBERER OF LIVING UNITS: NUMBER OF BEDROOMS: sy NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG / LtJC. 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 �D ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION �I�- ft PROPERTY LINE SO t 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 `) f ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION J016 , 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 G�yl�/L/zaG- DATE / /51 <br /> O <br /> H O ly <br /> A T <br /> DEPA R TM EN T USE NLY <br /> Application Accepted By Date Area Employee ID# <br /> Final Inspection By F w Date I �7_l{ / � E SP CIAL ERMIT-Approved by <br /> Character of Soil to D pth Ft. v Pit/Sump Soil Character: <br /> COMMENTS tg" GAA?E � <br /> Vw <br /> PE SC Received kc hec Amount Permit/ <br /> Code INFO B Cash Remitted Date Service Request# Invoice# Permit ID# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />