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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 CA L 09)953-7697 FOR INSPECTIONS EXPIRES 1 Y AR FROV DATE ISSUED <br /> JOB ADDRESS L�O� CITY/ZIP � <br /> I I q :j <br /> CROSS STREET ��-J�/��O \\� APN � V PARCEL SIZE ` p <br /> OWNER NAME �S /``�.'v� t�iv��'`S V <br /> PHONE <br /> OWNER ADDRESS 0( j ` �� �d.C� (� \` C^ CITY/STATE/ZIP L <br /> CONTRACTOR '�V N�`1C1,L�(� { J'\(��`�� (� PHONE <br /> CONTRACTOR ADDRESS J l �r�C Ems' \�� CITY/STATE/ZI �JP/(1 �tc <br /> LICENSE DFIC-42 ❑DC-36 OTHER (\ NUMBER7 31� 11 EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: COordi ates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION R AIR/ DITION ) ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMEN OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE I I COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 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 /> ❑/ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT '❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> I LEACH LINES . LEACHING CHAMBERS #of LINESLENGTH OF LINES ft <br /> / <br /> DISTANCE TO NEAREST WELL ft FOUNDATION n 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 It 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 I WIDTH 47.1f -ff, DEPTH `S ' ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It 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 /> MV114UM 48 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953/-7697 <br /> SIGNED ' TITLE L {� C3 DATE I /� <br /> O J <br /> DT <br /> Fr <br /> LEPARTMENT SE NLY <br /> Application Accepted By ate Area Employee ID#� <br /> Final Inspection By Date r J SPECT PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: <br /> Pit/ ump Soil Character: <br /> COMAAENT�_� , <br /> PE SC Received heck#/ Amount Permit/Code INFO B emitted Date Service Re nest# Invoice# Permit ID# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />