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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 3 YEAR/FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP <br /> CROSS STREET C �!/yY OUfa APN C O PARCEL SIZE <br /> d <br /> OWNER NAME J fi� � PHONE � <br /> OWNER ADDRESS AyIIT CITY/STATE/ZIP <br /> CONTRACTOR �lj ✓f e1L 'LS �U / ' �Xl _ PHONE <br /> CONTRACTOR ADDRESS ��c+,[r J' /� T J CITY/STATE/ZIP �/SG G Gh ` 4 <br /> LICENSE 11IIC-42 ❑FIC-36 OTHER NUMBER l/J 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 04 � REPAIR/ADDITION Ll ENGINEER DESIGNED/ALTERNATIVE <br /> LI REPLACEMENT Ll OUT-OF-SERVICE SEPTIC SYSTEM CI DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCAL ❑ 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_ 13 PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> �. LEACH LINES CI LEACHING CHAMBERS f #OF U _�. LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL t ! 'eL ft FOUNDATION 1a r� 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 [1 LENGTH ft DEPTH ft <br /> DISTANCE TO NEA TT WELL ft FOUNDATION ft PROP TrY 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 /> ❑ 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 /> MINI M 48 HOUP-ADV49CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)9533-7697 <br /> SIGNED TITLE Gil/ DATE !/ l <br /> if <br /> CZ H TH DE PA ITA ET <br /> PARTMENT USE OIAYLY <br /> Application Accepted B _ Date O Z Areamployee ID# S f`• <br /> Final Inspection By Date 11SP IAL PERMIT-Approved by <br /> Character of Soil to Dgpth of 3 Ft: Pi Sum Soil Character: <br /> COMMENTSOar <br /> PE SC Receivedheck Amount ate Permit/ Invoice# Permit ID# <br /> Code INFO B a Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />