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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 <br /> /PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Ot, CITY/ZIP o ' 'n <br /> CROSS STREET ILUuw♦he c,It ' APN PARCEL SIZE /,,7/ p <br /> OWNER NAME //�prn//r< ��/� �e PHONE <br /> OWNERADDRESS / GOi iG /3Ue- CITY/STATE/ZIP <br /> CONTRACTOR �Gla4-"Jz S/ PHONE 7!22 5Z)Z7 <br /> CONTRACTOR ADDRESS .) yL iti � pw CITY/STATE/ZIP 1 <br /> LICENSE 11A-42 ❑ IC-36 OTHER NUMBER EXPIRATION DATE JT Z <br /> T <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: C Or in tes X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: X, NEW INSTALLATION I R AIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> nN <br /> LATION WILL SERVE: Era RESIDENCE El COMMERCIAL L1 OTHER <br /> U <br /> MBERR OF LIVING UNITS: I NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br /> .a SEPTIC TANK TYPE/MFG ��L CAPACITY /,>GU gal #OF COMPARTMENTS Z <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION /"U ft PROPERTY LINE L ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 0- LEACH LINES LEACHING CHAMBERS #OF LINES 3 LENGTH OF LINES S ft <br /> DISTANCE To NEAREST WELL ]OG f- ft FOUNDATION w 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 L�9 ft DEPTH 425- ft <br /> DISTANCE TO NEAREST WELL /So 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 — TITLE �/�ZllcfGrs� DATE <br /> Ver <br /> � 419 <br /> F T /V <br /> � HT <br /> DS 4ARTMENT U SIE ON <br /> Application Accepted B Date Area Employee ID#-� <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil t epth of 3 Ft. Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received heck# Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Rem'ted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />