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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 a9)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 4 CITY/ZIP V 15-3 77 v <br /> 78 N7di� .r Ti AL 71 <br /> CROSS STREET F/1 /� APN f�"L160 - 2/ PARCEL SIZE 7— p <br /> / / 0 <br /> OWNER NAME ���LC:-4rj1 L- PHONE <br /> OWNER ADDRESS /DO0CITY/STATE/ZIP 'q0'7-,0z_ <br /> CONTRACTOR /,IzG, /J(=-7 PHONE Z"p2/7,/ /y09d <br /> CONTRACTOR ADDRESS �� z!?C'x CITY/STATE/ZIP <br /> LICENSE ❑ C-42 11, 'C-36 OTHER -Z/ NUMBER/ A! 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 I ENGINEER 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 /> [3MOUNDED WIDTH ft LENGTH ft DEPTH Clk 1[ <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE IA A, rAtFtl <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH Sd�, 1 7n ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LI_N 0, ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTHTH�NM�C�(/n�,. ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINEq� ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THATJ 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 H I ZA n11A AXE NOTICE REQUIRED FOR/NSP TIONS - PL SE CA 209 953-7§9 <br /> SIGNED TITLE ��� /�G DATE L� �G <br /> EPARTMENT US 810NLY /� l <br /> Application Accepted 13y Date Z110090 Area Employee ID# <br /> Final Inspection By - Date Z_ ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> ->G 'b o L07t4 a <br /> r4l <br /> PE F SC Received Check# Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B lRemitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />