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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 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP ti <br /> CROSS STREET APN 0o-Z/Q PARCEL SIZE x v <br /> OWNER NAME PHO 6 7 5 --6 / :FU <br /> OWNER ADDRESS / CITY/STATE/ZIP <br /> CONTRACTOR PHONE �aG— /✓ / /� <br /> CONTRACTOR ADDRESSCITY/STATE/ZIP� �' <br /> LICENSE L; C-42 I,�36 OTHER NUMBER�J�EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> C 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 ok DESTRUCTION r <br /> INSTALLATION WILL SERVE: Ip RESIDENCE COMMERCIAL / I_ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: f NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG 4L CAPACITY al #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG SCAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WL <br /> EL _- ft FOUNDATION ft PROPERTY LINE fl <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 It FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH It 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 /> HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIQNS-PLEASE CALL(209)953-769 <br /> SIGNED TITLE DATE <br /> TMENT <br /> EPARTMENTIIUSfIONLY <br /> Application Accepted Date zU Area It Employee ID# <br /> Final Inspection By Date I_ SPE AL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: f Pit/Sump Soil Character: <br /> COMMENTS ) CJ <br /> �� <br /> S�n <br /> SC Received Check#/ Amount Pe mitt <br /> Date Invoice# Permit ID# <br /> Code INFO B Cash emitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 H59� <br />