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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(209)953-7697 FOR INSPECTIONSEXPIRES 1 YEAR FRO DATE ISSUED <br /> JOB ADDRESS //F\ �'. CITY/ZIP V) LAAe,61v <br /> CROSS STREET 216 APN V/ /r7 LkV - PARCEL SIZE �/ y <br /> OWNER NAME PHONE V y J ll / I b33 r' <br /> OWNER ADDRESS V 11) �( �C'vr I(; �� CITY/STATE/ZIP t1I L �•t �� 1SZ'3� <br /> CONTRACTORyW(/�ce 1 U�I W'cw PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C C-42 ❑I C-36 OTHER 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 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 /> ----------------- <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 /> MI IMU 8 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTION - PLEASE CALL 209 95 -7 97 <br /> SIGNED J TITLE C��v-Vw_ct_ DATE } 3 <br /> UC cp <br /> UrAL <br /> —ILI i <br /> c EPARTMEN TIUS EJ.ONLY <br /> Application Accepted By 46w, Date �?— Area Employee ID# <br /> Final Inspection By Date QZl/�(�ZD 11SPE IAL PERMIT-Approved by <br /> Character of Soil to Dep o 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS ,Z �--z A kLy _ F- " <br /> PE SC Received Check#/ Amount Permit/ <br /> ode INFO B Cash Remitted Date Service Request <br /> # Invoice# Permit ID# <br /> D s3 S <br /> 442-01 <br /> /14/18 I O �`�C ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />