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t 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 ADDRESSO d _ CITY/ZIP Tra C ), <br /> _ -i <br /> CROSS STREET <br /> S 0 APN24�55 '?;aL)O ' ©S PARCELSIZE <br /> 0 <br /> OWNER NAME 1 OI /-'L LALvw PHONE <br /> J / T /l <br /> OWNER ADDRESS / �Ot� �� ^ / 47475:0C—,t�'VACITY/STATE/ZIP / / /Iia G y of <br /> CONTRACTOR�f�� PHONE <br /> CONTRACTOR ADDRESS / O ( � / 7�j' CITY/STATE/ZIP �{e ?G <br /> LICENSE �42 [10C-36 OTHER NUMBER / �/ �� EXPIRATION DATE ✓ rJ <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 /> [B' REPLACEMENT 7-an D OUT-OF-SERVICE SEPTIC SYSTEM IV DESTRUCTION <br /> INSTALLATION WILL SERVE: il RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: 4' NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG L. / VOD CAPACITY /Z O gal #OFCOMPARTMENTS <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 L 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 4 H R A VAN-CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-76/97 <br /> SIGNED TITLE ����A�2//QN��� DATE _2 —fj —2a_ <br /> v <br /> T <br /> a o <br /> O O <br /> R <br /> T <br /> •D PARTMENTJJSI ONLY //�� <br /> Application Accepted By Date Area 'C7 Employee ID# A <br /> Final Inspection By �Wl/ Date 2 L1SPECIAL�PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS �iF <br /> PE SC Received Che Amount Permit/ <br /> Code INFO B s Remitted Date Service Request# Invoice# Permit ID# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />