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t <br /> 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 I YEAR FROM DATE ISSUED <br /> yS9 / Z - <br /> JOB ADDRESS ��/�' Q//)�G I�-� CITY/ZIP_ �,-,�` <br /> n <br /> CROSS STREET APO PARCEL SIZE b <br /> 0 <br /> OWNER NAME &�� PHONE <br /> OWNER ADDRESS CITY/STATE/.ZIP <br /> CONTRACTOR /1n �, ��A/��cif/ _ PHONE <br /> CONTRACTOR ADDRESS37 ///.� ��— CITY/STATE/ZIP <br /> LICENSE ❑k-42 ❑0C-36 OTHER NUMBER 1/SrlOif� EXPIRATION DATE O d <br /> WATER TABLE DEPTH: 10 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION N' REPAIR/ADDITION U ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM 0 DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG Lel- — 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 /> 12L LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES /D ft <br /> DISTANCE TO NEAREST WELL SD 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 /> uk SUMPS WIDTH ! ft LENGTH 42� ft DEPTH k` ft <br /> DISTANCE TO NEAREST WELL 70' ft FOUNDATION /D ft PROPERTY LINE S 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLES y,�f 7r C- DATE O l <br /> F' <br /> N <br /> F T <br /> D E P A R T M E T LYSEO lVLY <br /> Application Accepted By Date Area Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Dept i of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received f Amount Permit/ <br /> Code INFO B Cash emitted Date Service Request# Invoice / Permit ID# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />