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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 YEAR FROM DATE ISSUED <br /> `A <br /> JOB ADDRESS " O Vco1C;� c;- CITY/ZIP �L O G 5 ZZ V <br /> CROSS STREET -` �►J �C�C"{ APN&0-1 ' PARCEL SIZE <br /> C <br /> ^^ C <br /> OWNER NAME 1����� PHONE Z(!j0 ''7-"C-\ A <br /> OWNER � <br /> ADDRESSy� �/ `` SC�N CITY/STATE/ZIP <br /> CONTRACTOR 5� C�01t�A /^�.�.� PHONE <br /> CONTRACTOR ADDRESS 1A At ✓��� � ` � CITY/STATE/ZIP <br /> LICENSE ❑I1C-42 ❑I '.0-36 OTHER NUMBERS ) 5 r EXPIRATION DATE ZO -2- <br /> WATER <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT ZOO &a OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: ;9- RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: ` NUMBER OF BEDROOMS: ?7 NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG ` CAPACITY \-2- 0Q gal #OF COMPARTMENTS Z <br /> ❑ GREASE TRAP TYPE/MFG f 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 /> 0 LEACH LINES LEACHING CHAMBERS IeJFt��RA"CcZ�-S #OF LINES 2— LENGTH OF LINES 5 Z ft <br /> It <br /> i <br /> DISTANCE TO NEAREST WELL�ft f FOUNDATION�(FO I ft PROPERTY LINE Z 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 /> SEEPAGE PITS NUMBER WIDTH f ft DEPTHj* <br /> DISTANCE TO NEAREST WELL OUNDATION 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 AQVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-7§9 7 <br /> SIGNED TITLE ��' l ( fes CO, DATE I L <br /> a 019 <br /> c <br /> F H 4 <br /> HT <br /> LL <br /> D€ ARTMEN SE Y <br /> Application Accepted B Date l Area � <br /> Employee ID#,4f <br /> Final Inspection By Date ❑ SPEC AL PERMIT-Approved by <br /> Character of Soil to Dept*t: Pit/Sump Soil Character: <br /> COMMENTS <br /> s , s s �� <br /> PE SC Received Ch Amountermit/ <br /> Code INFO B ash emitted Date Service Request# Invoice# Permit ID# <br /> 42-01 V Q„/ �Qi� C �` !' Ut ASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />