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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' (;0-90N <br /> � f 1 (fCCALL(209)953-7697 FOR INSPECTIONS EXPIRES 1gYEAR FROM DATE ISSUED <br /> JOB ADDRESS 1-d 2-0 IV l7�`-90`� (� �� A4 CITY/ZIP S7Vw'M N (f4-�Q s- / f" <br /> CROSS STREET /11 (/�t (�[ (kms APN 14 Nl r (0 PARCEL SIZE /r <br /> OWNER NAMErel ray e�a,w PHONE 570 7/1� <br /> OWNER ADDRESS 94H&&)� ( S CITY/STATE/ZIP 33 <br /> CONTRACTOR /y V� �/� y1 N PHONE (0 7 US (r U U j N <br /> CONTRACTOR ADDRESS �T/ �1/111�1r/ CITY/STATE/ZIP C <br /> 7� ,J ,6 <br /> LICENSE ❑0C-42 ❑EC-36 OTHER OWNM -�uw?A NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT## LAND USE APPLICATION# <br /> TYPE OF WORK: _ NEW INSTALLATION REPAIR/ADDITION Li ENGINEER DESIG D/ALTERNATIV <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM 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 U 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 AbA ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ' <br /> El MOUNDED WIDTH ft LENGTH ft DEPTH tt <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH S._ Z 9Ae„ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN '0 _ ft <br /> L3 DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH y�[Tj,RDIV'��Uft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE �/ZT,�q� 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 /> MINIM 4 H R ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> ,-,1PLEASE CALL 209 953-7697 <br /> SIGNED TITLE D�/�'� �y�`�/ DATE D �. <br /> ` 'DEPARTMENT USE ONLY I` <br /> Application Accepted By Date Area Employee ID# <br /> Final Inspection By Date 2 2_ L� r-] SP IAL PERMIT- by <br /> Character of Soil to De th of 3 Ft: Pit/ ump Soil Character: <br /> COMMENTS <br /> 1` e rxcl -1 - �� Yx�S r owv; ,r a VL% - <br /> PE SC Received Check#/ Amount ate Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> 2( d-2- <br /> 42-01 <br /> -2 -42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />