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1 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 /> JOB ADDRESS S �/��j-6,,4 CITY/ZIP yMGn►�-GCs4 /`/g ��3�i�_ <br /> n <br /> 7 <br /> CROSS STREET /Viy / �`7 APN [// �C) z'0 V PARCEL SIZE ` 6 <br /> C <br /> OWNER NAME 1 c t ,' b r-nAL(q A.4 fir kt/C PHONE /T1 C'�?�J .� P <br /> OWNER ADDRESS � S[ i li CITY/STATE/ZIP L�I�Gy�- Ci� 5- 3-36, <br /> CONTRACTOR /T� r� �{_ �s¢C. PHONE q <br /> CONTRACTOR ADDRESS` _Cif `;j S CITY/STATE/ZIP S /%,.4 J�i/I` L S�'✓6 <br /> T <br /> LICENSE D0C-42 DOC-36 OTHER ,�— NUMBERI(J­,�k - _EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION u ENGINEER DESIGNED/ALTERNATIVE <br /> 0 REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM 1.7 DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 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 /> Cd LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES 0 LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> FILTER BED WIDTH 16� ft LENGTH 4 � ft DEPTH ft <br /> DISTANCE TO NEAREST WELL I Qbj ft FOUNDATION 3-no' ft PROPERTY LINES r It <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 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 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 / c <br /> SIGNED TITLE `-0rl )tt 1(" DATE to <br /> _ T <br /> D <br /> I <br /> Xf­z/v TM <br /> � E T <br /> -41 <br /> PARTMENT SE O VLY <br /> Application Accepted By _ Date 1 Area ployee ID# <br /> Final Inspection By Mt LA IJ r Date 17j, fil ❑ SPE IAL PERMIT-Approved by <br /> Character of Soil to Depth of t: it/Su p Soil Character: <br /> COMMENTS Wo I <br /> PE SC Received Check Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Remitted Service Request# <br /> sRoo 3a3 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />