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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 EXPIRES1 YEAR FROM DATE ISSUED <br /> JOBADDRESS ��wC 7s -5 S'TDCtC7t9w 37'-" CITY/ZIP L'®4_41%_- 52 1/�O Z' <br /> CROSS STREET 4AI APN PARCEL SIZE <br /> 6 C <br /> r� <br /> OWNER NAME PHONE <br /> w <br /> OWNER ADDRESS[[ CITY/STATE/ZIP <br /> CONTRACTOR33 Cd 17ST��t�T OnC ?{ SEPi'JxF �N9 C, PHONE 10 <br /> CONTRACTOR ADDRESS 1C577__222Cl,4FtZ_#,j caetF4_- D2 SXcc1T-�F2A:PCITY/STATE/ZIPSA--fl 4 <br /> LICENSE -42 ❑ IC-36 OTHER NUMBER5rZZ'y2b EXPIRATION DATE D���O/2e':; O <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: CI NEW INSTALLATION _, REPAIR/ADDITION I I ENGINEER DESIGNED/ALTERNATIVE <br /> 1.1 REPLACEMENT IJ OUT-OF-SERVICE SEPTIC SYSTEM *----DESTRUCTION 7—,"V k <br /> INSTALLATION WILL SERVE: L.] RESIDENCE ❑ 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 0 PKG TX PLANT Q SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES I ' LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL 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 /> C3 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 /> MINIM M 8 1400P AOMNCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED ' TITLE l�P�S F1V_r DATE 0 5/2--2 <br /> M_t TV <br /> lion knacki Al <br /> D P E T <br /> )::�� <br /> PARTMENT USE ONLY <br /> Application Accepte4De <br /> / Date Area Employee ID# <br /> Final Inspection By Date IJ SPECIAL PERMIT-Approved by <br /> Character of Soil tohof 3 Ft: Pit/Sump Soil Ch racter: <br /> CONI ENTS r, fr <br /> PE Sc Received Check#/ Amount Permit/Code INFO B Cash Remitted Date Service Request# Invoice# Permit ID# <br /> V,soy 5 S 22. SITZ 2 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/16 <br />