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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 -yam, CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 9:322 ✓ e nL,/ —CITY/ZIP �(/(Z a <br /> n <br /> CROSS STREET AP <br /> NI PARCEL SIZE Y <br /> �02')L�!'Yl-in,r, r� � d <br /> C <br /> OWNER NAME tNVV A /i�y/GJL PHONE 91 3L O /6 7 H <br /> OWNER ADDRESS '.�a IMS // CITYISTATE/ZIP <br /> CONTRACTOR �1.��1� ��41 St.Ofie PHONE <br /> �S/�Z7 <br /> CONTRACTOR ADDRESS �J�/tL 6 �jiX /�iC p CITY/STATEIZIP fj/GZ1� <br /> LICENSE ❑x-42 ❑CIC-36 OTHER NUMBEREXPIRATION DATE �G/�jfD/yJ <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: Q NEW INSTALLATION REPAIR/ADDITION U ENGINEER DESIG D(ALTERNATIVE <br /> REPLACEMENT �_ /N�/f'CL7 OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: i, RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: / NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG 4Z CAPACITY � - gal #OF COMPARTMENTS d1 <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL A&We- ft FOUNDATION ft PROPERTY LINE zO 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 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 it 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 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 /> UIwchl <br /> IV <br /> Er <br /> 1+ <br /> D PARTMENT USE O LY <br /> Application Accepte4Deth <br /> Date Area Employee ID#_ <br /> Final Inspection By Date C\ ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil toof 3Ft: Pi Sump Soil Character: <br /> COMMENTV&G9jP_ LIm�C ck afirb. <br /> PE SC Received CCheck# Amount Permit/ <br /> Code INFO B ash R mitted Date Service Request# Invoice# Permit ID# <br /> a 10.08-IP) 5 002)33Z <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />