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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 <br /> � EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS � � S u h(is A CITYIZIP,'//�ICAr/Y IL-,e-z� <br /> CROSS STREET 7)V,-14rk �jJ� APN ��y O J (/�� PARCEL SIZE <br /> OWNER NAME e Z VM;-AM e, i^1�e-_Z,t- a r Lt Y' 'w [I.li PHONE <br /> OWNER ADDRESS �c��►��-�/ CITY/STATE/ZIP <br /> CONTRACTOR �6--f4l64 a- -/- �C Lt PHONE <br /> CONTRACTOR ADDRESS FC� fZSL G��� CITY/STATE/ZIP <br /> LICENSE 30C-42 ❑❑C-36 OTHER NUMBEREXPIRATION DATE_ I1 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT#_,,, LAND USE APPLICATION# <br /> TYPE OF WORK: L NEW INSTALLATION REPAIR/ADDITION D ENGINEER DESIGNED/ALTERNATIVE <br /> 0 REPLACEMENT 0 OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: L�SIDENCE ❑ COMMERCI ❑ OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG PSL- CAPACITY (p,5 3 gal #OF COMPARTMENTS,r1, <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ?�r ft FOUNDATION Jr 1 ft PROPERTY LINE _30ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 0.1 FILTER BED WIDTH If 0r ft LENGTH V cg�yI ft DEPTH 19" ft <br /> DISTANCE TO NEAREST WELL (0 6 , ft FOUNDATION ' t ft PROPERTY LINE S 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 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 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE 45 117' C- {fid r DATE �fj 2:5- Iq <br /> 419 <br /> o co N� <br /> 10 Lo <br /> t <br /> NT <br /> -� PARTMENT U E ONLY 22 <br /> Application Accepted B Date Area J Employee ID# <br /> Final Inspection By. Date ❑ SPE AL PERMIT-Approved by <br /> Character of S 11 Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMEN t. <br /> 61 1- <br /> KnID# w <br /> PE SC Received Chec Amount ate Permit! Invoice# Perm <br /> Code INFO By— Remitted 9 Service Request# <br /> Zs 58008 I U a <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />