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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 /> JOB ADDRESS J S 7. . CITY/ZIP <br /> CROSS STREET APN 670 - 0lb PARCEL SIZE <br /> `J o <br /> OWNER NAME (�/�✓1- = / CiL,. PHONE <br /> OWNER ADDRESS� �� (� i t✓�� CITY/STATE/ZIP <br /> / <br /> CONTRACTOR c;N /?L / PHONE_SL>> <br /> CONTRACTOR ADDRESS 3 5%� �/�/ a. //-" �'� CITY/STATE/ZIP <br /> LICENSE WC,42 11 C-36 OTHER NUMBER �`7—lciY� EXPIRATION DATE <br /> WATER TABLE DEPTH: Zy ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # F BUILDING PERMIT## LAND USE APPLICATION## <br /> TYPE OF WORK: NEW INSTALLATION jX REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: tF- RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: r NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG S/x�v` 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 /> LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINESft <br /> DISTANCE TO NEAREST WELL /SU t' ft FOUNDATION ft PROPERTY LINE 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 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 "`v TITLE DATE <br /> F Qj <br /> M <br /> r <br /> D ARTMENT EONLY <br /> Application Accepted ByK4t Date 11 Area Employee ID#� <br /> Final Inspection By "FL Date GI ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth'of 3 Ft: it/Sump Soil Character <br /> COMMENTS f U J s1] <br /> PE SC Received ec Amount Da a Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />