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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 2'70'2 S ST14G1c-s29-T1 g7 CITY/ZIP LCD t7� 9sz�c0 v <br /> CROSS STREET E t+A(2,VA)Ey/ L-V APN I?00-5— PARCEL SIZE <br /> 5 <br /> OWNER NAME PHONE v <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> C /,gyp <br /> CONTRACTORTS CeyVS•n10r•LA'�A7 J�r �-tL, TwG, <br /> r / PHONE (1A.)CONTRACTOR ADDRESS 45T-,-/7y -4 eA&-e?< .S //�ZeoCITY/STATE/ZIP S-llYc7IZ9ft'-2/u�l+-oS(A <br /> LICENSELICENSE Sr� <br /> S82s <br /> ❑I 1C-36 OTHER NUMBER5;F21-C13& EXPIRATION DATE 0(0 /50/ 0 2 <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 I REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM T✓ DESTRUCTION - )Nk <br /> INSTALLATION WILL SERVE: ❑ 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 ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES Li 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 /> ❑ 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 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 9_53-76_97 <br /> SIGNED TITLE ES �(�✓T— DATE 0 s/zz�I Cl <br /> LY YE F1 U <br /> aI CC qm�N <br /> T <br /> PARTMENT US ON Y <br /> Application Accepted B Date Area Employee ID <br /> Final Inspection By Date ❑ SPECI L PERMIT-Approved by <br /> Character of Soil to of 3 Ft: Pit/Sump Soil haracter: / <br /> COMMENTS 4 .� 7J�QD/ <br /> Gt <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO B Cash Remitted Date Service Request# Invoice# Permit ID# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />