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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> S;>N JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> o NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS C�L��� �lOa�/ 11A1 __ ____..CITY/ZIP <br /> CROSS STREET AP�AId ' _ n <br /> PARCEL SIZE •` <br /> OWNER NAME�fPiI�GJClL' IzG PHONE <br /> OWNER ADDRESS S'r1yHe CITY/STATE/ZIP <br /> CONTRACTOR ZG17l10z /z6l'/ /111;0 rr ___ PHONE -3651-S-Oz_-7 , <br /> CONTRACTOR ADDRESS ��T�X_ CITY/STATE/ZIP y`�rY/�✓ <br /> LICENSE ❑AC-42 ❑nC-36 OTHER NUMBER EXPIRATION DATE �G <br /> WATER TABLE DEPTH.. ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: 11 NEW INSTALLATION ig, REPAIR/ADDITION U ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT n OUT-OF-SERVICE SEPTIC SYSTEM 1.1 DESTRUCTION <br /> INSTALLATION WILL SERVE: 14- RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG Y/Vi wti 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 S-5- ft <br /> DISTANCE TO NEAREST WELL 14V S- ft FOUNDATION SU r ft PROPERTY LINE r ft <br /> ❑ FILTER BED WIDTH ft LENGTH It 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 /> I SUMPS WIDTH ft LENGTH zv, ft DEPTH JU 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 It <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 rate DATE U $ <br /> kA <br /> ti <br /> FFH I I L I <br /> N <br /> A <br /> .- A EPA RTME TAISE (IN LY <br /> Application Accepted ByDate Area _�� ' Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to 10111 of F . Pit/Sump Soil Character: <br /> COMMENTS /cj _ AA-- /A/ Tltlu-� <br /> ! e ja4A"Z-f__- (.CLQ a SAS Cs <br /> PE SC Received Teck#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By sl Remitted Service Re uest# <br /> 0 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />