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s <br /> 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 <br /> RES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS / T /J� ANAL CITY//ZIP <br /> CROSS STREET �Qi�L��( Z1'�, APN zeq �t0 / PARCEL SIZE - <br /> OWNER NAME ,Q� �J/'.3 L- /� /PHONE 5-10 <br /> OWNER ADDRESS 14:6 d Z T ✓I mar CITY/STATE/ZIP -4 .vaeA- Qo?.oZ <br /> CONTRACTOR 1AZZ01 UNC PHONE 2oy�ysr 7 90 /� <br /> CONTRACTOR ADDRESS pV p��/� �Up� CITY/STATE/ZIP , GIL��O/1J /Q sz� <br /> LICENSE ❑! C-42 [I I-C-36 OTHER NUMBER 74" 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 ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM e�- 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 LIRE 44 <br /> • ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH •\�� "�'►f.�_ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIINEp, OWC ft <br /> [3 MOUNDED WIDTH ft LENGTH ft DEPTH AN � t �7 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROP LI I 4447��� ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH E JJ �/N�O ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROP�eEP�A, ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH EIVT 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 /> MINIMUM-148 HO ADVANCE NOTICE RE UIRED FOR/NSP l NS-PLEASE CALL 209 953- 697 <br /> SIGNED TITLE F� / GTd� DATE Z t►� <br /> F�F <br /> ArwEPARTMEN VUSt ONLY <br /> Application Accepted By Date Z �� Area .S Employee ID#�� � �[ <br /> Final Inspection By Date Z ❑ SPECIAL PE MIT-Approved by <br /> Character of Soil to Depth f 3 t: Pit/Sump Soil Character: <br /> COMMENTS �1 L i '[ i L ✓bvi d&A <br /> V <br /> PE SC Received Chec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO BV as Remitted Service Request# <br /> Z f <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />