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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 /� (1 CALL 209 953-7697 FOR INSPECTIONS EXP <br /> IRES <br /> I YEAR FROM DATE ISSUED <br /> JOB ADDRESS . ��'I (F 1)'y,(ko I tyrf e I C�. CITY/ZIP <br /> CROSS STREET A f OK U/RY APIN ?SS ` 7,0017- PARCEL SIZE ?JO 7— <br /> OWNER <br /> OWNER NAMEA PHONE <br /> OWNER ADDRESS '3�1. S n, ITY/STATE/ZIP /Y Id�41 lQ1R M'3446" C.1 f. J3�i 2 <br /> CONTRACTOR HONE 101 r(JS -9(m <br /> � 1 <br /> CONTRACTOR ADDRESS O t' CITY/STATE/ZIP 1 tkcy <br /> i r <br /> LICENSE 01 C-42 ❑ C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: )C NEW INSTALLATION I REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: q NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY k on gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG J CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL 1-I 1 ft FOUNDATION 10113 ft PROPERTY LINE (I ? ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS #OF LINES /—L LENGTH OF LINES CGU\ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION -'n ft PROPERTY LINE I' z O ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> (3 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 It 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 /> MINIMIVM 48 HO R ADVANCE NOTICE RE UIRED FOR INSPECTIONS - PLEASE CALL 209 3-7697 <br /> SIGNED TITLE DATE <br /> 11 YlyflFINIT— <br /> UVED <br /> T D"RTMEI.4T , <br /> DEPARTMENT jUSE ONLY <br /> Application Accepted By Date /,S - Area <br /> @f� Employee ID# � <br /> Final Inspection By_ Date ElSP CIAL PERMIT-Approved by <br /> Character of Soil to Dept of 3 Ft: Pi ump Soil Character: <br /> COMMENT rr� i7 L S <br /> c 1,dL t 24-r) <br /> PE SC Received Che #/ Amount to Permit/ Invoice# Permit ID# <br /> Code INFO B ash Remitted Service Request# <br /> 14 Vt It�7S(I'_06 v y <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />