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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 tYEAR FROM (DATE ISSUED <br /> JOB ADDRESS CITY/ZIP S^L Z tP <br /> CROSS STREET APN PARCEL SIZE p <br /> OWNER NAME ,��� /� jti11 PHONE <br /> OWNER ADDRESS p fy CITY/STATE/ZIP / <br /> CONTRACTORg j� PHONE 3619- <br /> CONTRACTOR ADDRESS �y �tiCT/ s Jj�� /�iC CITY/STATE/ZIP ri�.(cYr-�cJ <br /> LICENSE LJ;IL-42 ❑I iC-36 OTHER NUMBER7 EXPIRATION DATE�Nlioe <br /> 1 1 <br /> WATER TABLE DEPTH: 10 V`� ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> 11 PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION I i ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION <br /> LINSTALLATION WILL SERVE: �RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: , NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG �(/�:y:, 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 /> f�— LEACH LINES X LEACHING CHAMBERS #OF LINES LENGTH OF LINES 51� / ft <br /> DISTANCE TO NEAREST WELL JUO:Je— ft FOUNDATION j T' ft PROPERTY LINE 5 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 .1j? / <br /> ft LENGTH z 7 ft DEPTH !Q ft <br /> DISTANCE TO NEAREST WELL AA tC- ft FOUNDATION /D 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED �� TITLE �y!/ DATE Z11,1Z <br /> �p <br /> I JA- <br /> 0 O <br /> T� <br /> N <br /> DEPANTAIS& ONLY <br /> Application Accepted Date Area Employee ID#� i <br /> Final Inspection By Date 11 SPP IA�IT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/ ump Soil Character: <br /> COMMENTS <br /> PE SC Received heck Amount Permit/ <br /> Code INFO B ash Remitted Date Service Request# Invoice# Permit ID# <br /> Aup <br /> 2�J�f3 11 Iti I� s lY�� <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />