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5 \ <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 pPERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP <br /> CROSS STREET �e►2nke-e APN V PARCEL SIZE <br /> v <br /> (� <br /> y/ G <br /> OWNER NAME L-)D 11✓ 1 / � iQL 1 PHONE Y//-6 J,/0 �y <br /> OWNER ADDRESS C [� .;;��. CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS UU i CITYISTATE/ZIP yT�t�/ <br /> LICENSE b4-42 ❑EIC-36 OTHER NUMBER OYS- EXPIRATION DATE'&>zw" J <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION j' REPAIR/ADDITION Ll ENGINEER DESIGNED/ALTERNATIVE <br /> n REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: / NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFGCAPACITY 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 D LEACHING CHAMBERS #OF LINES LENGTH OF LINES 7G ft <br /> DISTANCE TO NEAREST WELL/ FOUNDATION6� fft 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 /> ❑ 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 /> rr <br /> 9- SEEPAGE PITS NUMBER �_ WIDTH 3 ft DEPTH S ft <br /> DISTANCE TO NEAREST WELLISQ, ft FOUNDATION S ft PROPERTY LINE/O 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 /> MINIPAUM48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTION S - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE <br /> f <br /> 44 <br /> T <br /> EA Q /N <br /> L.T <br /> N <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date, Area Employee ID#� <br /> Final Inspection By Date 2 ElSPE IAL PERMIT-Approved by <br /> Character of Soil to De i of 3 Ft: Pit/ ump Soil Charact r: <br /> COMMENTS f f <br /> PE SC Received Check Amount Permit! <br /> Invoice 4i Permit ID# <br /> Code INFO Bv Remitted D to Service Request# <br /> p 3� z 5Roo1131& <br /> 42-01 ONSITE WASTEWATE=R TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />