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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(2?9)953-7697 FOR INSPECTIONS XPIRES 1 YEAR�JFROM DATE ISSUED <br /> JOB ADDRESS C of u is CITY/ZIP �( IV �O�6v <br /> CROSS STREET APN l�'�� �/ PARCEL SIZE V-Lq <br /> OWNER NAME �'n PHON�5 <br /> OWNER ADDRESS w C// 'l �jJ G CITY/STATE/ZZII/P1 S/L</ 110jGJ7 <br /> CONTRACTORi Q` C "! PHONE I�' 1J/ <br /> CONTRACTOR ADDRESS 8 U S rt uv �C CITY/STATE/ZIP Jt-C 1 i <br /> LICENSE ❑. C-42 ❑ C-36 OTHER NUMBER yS S� 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/ADDITIONNGINEER DESIGNED/ALTERNATIVE <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 ❑ 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 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 /> IMUIW-48 H R ADVANCE NOTICE REQUIRED FOR INS/PEC ION - PLEASE ALL 209/953-769/7 <br /> ri SIGNED 6TITLE 11[e -C �� DATE L ^ ^C <br /> J <br /> N O Nry <br /> —k- <br /> EPARTMENT WS E b N L Y <br /> Application Accepted ,y Date l Area Employee ID#� <br /> Final Inspection By Date ❑ SPEC AL PE MIT-Approved by <br /> Character of Soil to Depth o Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check Amount Permit/Code INFO B sh Remitted Date Service Request# Invoice# Permit ID# <br /> 5_ —4 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />