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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-REFUNDABLEPERMITCALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /QL j l�CITY/ZIP L //�_ _G� �6�-77 <br /> CROSS STREET �� �i� APN ` d / 7 U Z�5 PARCEL SIZE y <br /> OWNER NAME �,�oL OGsTJ �/" PHONE Sjo �/l/ Yo3z <br /> OWNER ADDRESS �O G✓�Is�'E b /7�Zo� CITY/STATE/ZIP^ Q �j <br /> CONTRACTOR ! (i. I�/9�jQN/riX PHONE .i of 77 /4/Q 47 <br /> CONTRACTOR ADDRESS 1t/ /� v J� CITY/STATE/ZIP <br /> LICENSE ❑1 !C-42 Eli C-36 OTHER NUMBER 7id�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: NEW INSTALLATION REPAIR/ADDITION �^ ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM p 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 LINEft— ft <br /> L3 SUMPS WIDTH ft LENGTH ft DEPTH \r ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LI ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH J� ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTTI aL+�L,. V ft <br /> L3SEEPAGE PITS NUMBER WIDTH ft DEPTH '4zZ 6Z'MC0tj"'_. ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 'PgR 'q'--�_ 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 8 H NCE NOTICE REQUIRED FOR INS P TIONS - PLEASE CALL 209 953-7.697 <br /> SIGNED TITLE DATE Z� <br /> -D PAR TMENT USE ONLY <br /> Application Accepted Date �!z 7"0 to Area LS Employee ID# f� <br /> Final Inspection By Date A L -26 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil toDepthef 3 Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received hec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash Remitted Service Request# <br /> 024 - 3SzZ1� I s to <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />