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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 S S CITY/ZIP /2011 ,�' 2:UZ9 <br /> CROSS STREET kl 1C APN C)L l r 170 - 4-1-- PARCEL SIZE <br /> C <br /> OWNER NAME )PHONE <br /> OWNER ADDRESS fi1/'f/"1 G CITY/STATE/ZIP <br /> CONTRACTOR Z_e_4 441_ //,///a//1_-1 _/AvyJ PHONE <br /> CONTRACTOR ADDRESS Y%(p �sC/LCw /���� �� CITY/STATE/ZIP <br /> LICENSE 111*42 01 IC-36 OTHER NUMBER EXPIRATION DATE /0/66/4; <br /> WATER TABLE DEPTH: t/ ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION h ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> ItN <br /> LATION WILL SERVE: ❑ RESIDENCE �. COMMERCIAL El OTHER <br /> U <br /> MBERR OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG CAPACITY J gal #OF COMPARTMENTS Z <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> -7 <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION / / ft PROPERTY LINE 160 ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 04 LEACH LINES LEACHING CHAMBERS #OF LINES� LENGTH OF LINES �� ft <br /> DISTANCE TO NEAREST WELL S-D /` ft FOUNDATION ft PROPERTY LINE jGd d- 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 /> 1 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 /> MINIUUM 48 HDUR_ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 3-76 7 <br /> SIGNED TITLE e!��1 DATE lz/ro/y <br /> J <br /> R N U <br /> P <br /> EPARTIMNTSE NLY <br /> Application Accepted B Date0 Area Employee ID# <br /> Final Inspection By Date ` ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth o Ft: -;"4 t.0 Pit/Sump Soil Character: °U <br /> COMMENTS ' t <br /> Appe <br /> PE Sc Received Ab e c kffO Amount Date Permit/ Invoice# Permit ID# <br /> Code_ INFO By Cash Remitted I I Service Request# <br /> 009 150 -- <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />