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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 �EXPI ES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �/ Gveu 4. CITY/ZIP J!`OG 7WA) U <br /> CROSS STREET Go/.I �i��ND APN �� �O SOSZ PARCEL SIZE Y <br /> v <br /> L ? v <br /> OWNER NAME PHONE ��� y ��+ ' y <br /> �3 7/J fi / /�//� 'S TZT CITY/STATE/ZIP <br /> OWNER ADDRESS -6 <br /> CONTRACTOR — PHONE X201 <br /> CONTRACTOR ADDRESS /'O IgO.0 �3 2� CITY/STATE/ZIP <br /> LICENSE ❑IJC-42 ❑L C-36 OTHER NUMBER /1(/L7 3 EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I I NEW INSTALLATION REPAIR/ADDITION I iCIQGINEER DESIGNED/ALTERNATIVE <br /> 11 REPLACEMENT LI OUT-OF-SERVICE SEPTIC SYSTEM 11 DESTRUCTION <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 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 LIN ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> VV7DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE * ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH 1A Ai ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERZY LINE 20 ft <br /> CAN <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH 9� QUIN ft <br /> Nb7�AI GA ti v <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPE MENT ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH TMENT 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 /> MINIMU 48 HOfJR ADVANCE NOTICE REQUIRED FOR/NSP TIONS - P4E4SE CALL 209 953-,7697 <br /> SIGNED TITLE DATE <br /> EPARTMENTiUSE ONLY <br /> Application Accepted B Date 11z14z0Q Area Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 F . Pi Su Soil haracter: <br /> COMMENTS ' ,o ' ✓!I r Z � a-t-�o <br /> k- r" Q.z v k w-ik 4A ro <br /> PE SC Received hec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By —C-a-sh Remitted Service Request# <br /> 22/ S 5 121 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />