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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 INSPECTIONS EXPIRES 11 YEAR FROM DATE ISSUED <br /> JOB ADDRESS / /Vda <br /> dA,) CITY/ZIP -7-12/9li V <br /> CROSS STREET /`- V APN � (/ PARCEL SIZE <br /> 0 <br /> 0 <br /> OWNER NAME <br /> PHONE <br /> T,f4 <br /> OWNER ADDRESS �� �./l//L (��/✓7G�' //A 3-/� CITY/STATE/ZIP 1; <br /> CONTRACTOR Ale-- PHONE <br /> CONTRACTOR ADDRESS /?r7&A 3�.j CITY/STATE/ZIP J/OLZ"7�//� C // <br /> LICENSE Eli C-42 0'1C-36 OTHER -Z/ NUMBER 74�fZ 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: I_' 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 /> ❑ 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 /> MINIMUM HOU ADVAN E NOTICE REQUIRED FOR INSPE TIONS - PLEASE CALL 209 953-769 <br /> SIGNED TITLE DATE Z L <br /> N <br /> N IR N E T L <br /> EPA R TM EN TV S B ONLY a <br /> Application Accepted B A- k Date Area Employee ID# <br /> Final Inspection By — Date zozo ❑ SP CIAL PE MIT-Approved by <br /> Character of Soil to Depth of 3 F Pi Sump Soil Ch ractp: <br /> COMMENTS `` �L l�eflb YIC S 0 uC br <br /> �d r <br /> PE SC Received # Amount ate Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> >"Z,- l� o <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />