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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 AA/ V CITY/ZIP J ivL L O�l� SZ U <br /> CROSS STREET Rl9G O nJ APN (/ PARCEL SIZE <br /> OWNER NAME �. L4i�/✓Ii�Tla�a�' /�i/...�7i�/G T PHONE <br /> �J � <br /> OWNER ADDRESS _) V 3 Li. ew u S>.2EET CITY/STATE/ZIP <br /> CONTRACTOR i .E PHONE O /�,��/ PC, Q�r' <br /> CONTRACTOR ADDRESS Z v CITY/STATE/ZIP <br /> LICENSE ❑CIC-42 ❑inC-36 OTHER 04 NUMBER EXPIRATION DATE <br /> / - I z9w: <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: LI NEW INSTALLATION C REPAIRIADDITION 1_I ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: 11 RESIDENCE I I COMMERCIAL I OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> 14, 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 AR IVA <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH r, <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE V� <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE A, O <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH Ar_Q1J/A1-- t <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH �TMFAft. <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 /> MINIMU 48 H R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-76 <br /> SIGNED TITLE o4 7 4* a DATE Z <br /> 00 <br /> Of <br /> �. DEPARTMENT USE OAILY <br /> Application Accepted By Date Area Employee ID#, <br /> Final Inspection By Date ❑ SPE AL PERMIT-Approved by <br /> Character of Soil to Dept of 3 Ft:J <br /> *.tls "Soil Character: <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO BCash RerWtted Service Request# <br /> aS 1 2311 Sr2 l70 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 6)t�*67632,3 <br />