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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 GO/{I CITY/ZIP a7 �C' <br /> - <br /> CROSS STREET /�GON .F„SL.�f�D O.D APN (TI i V J PARCEL SIZE p <br /> 0 <br /> OWNER NAME ��G/ �li l /� �ie�c/ PHONE S/6-(J �� 7 7 N <br /> OWNER ADDRESS ��7 ? �g,,' �/�/� -5rio-i- CITY/STATE/ZIPP - /OC r�J� Z <br /> CONTRACTOR �I(/� x/41 / PHONE <br /> CONTRACTOR ADDRESS �17 'r �j A CITY/STATE/ZIP-71' <br /> LICENSE ❑LC-42 ❑I IC-36 OTHER ' 1414 NUMBER Z"7 EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: I I RESIDENCE 1 1 COMMERCIAL I I OTHER <br /> NUMBER 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 LIN ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY I �/1�_ ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ��I/ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERT ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH 1010 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROP4 U� ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH %�CT DNMF H�' ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINft <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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 <br /> SIGNED TITLE DATE <br /> DEPARTMENT USE OAILY <br /> Application Accepted By Date 7 Area Employee ID# r <br /> Final Inspection By Date / D SPECT L PERMIT-Approved by <br /> Character of Soil to Dept o/3 Ft: PiUS mp Soil Characterr: .L <br /> COMMENTS j_�,r - � GQ� G�S� {S�� l�IN f (4 -ZA <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Bv Cash Remitted Service Request# <br /> 1 23 ►�I 00 �t <br /> 42-01 ��� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 / <br />