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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 A EXPIRES 1 YEAR FROM DAT ISSUED <br /> JOB ADDRESS G Y CITY/ZIP <br /> J f -� <br /> CROSS STREET `�6Pr �-P A P N J!225 " I 1 PARCEL SIZE J j <br /> � n L� 0 <br /> OWNER NAME /0jj Q�QI"� �/t7(1^O I��oes- PHONE �/�n y8y7 V, <br /> OWNER ADDRESS O PD/V "JV ( CITYISTATE/ZIP <br /> CONTRACTOR 4�4 q/ ([`G <br /> v�fled, e}fI PHONE 7G 11 - '7"' / r-0,2 7 <br /> CONTRACTOR ADDRESS 3 /f�TC�`) �(e �r Q CITY/STATE/ZIP <br /> LICENSE ❑'�_42 ❑ C-36 OTHER NUMBER ! S/�j EXPIRATION DATE <br /> 1 � <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 I i ENGINEER DESIGNED/ALTERNATIVE <br /> I I REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: 1 NUMBEROF BEDROOMS: NUMBER OF EMPLOYEES: <br /> L3SEPTIC TANK TYPE/MFG &*Sh''1 2 leONC'eck 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 Clffi*j4+f #OF LINES LENGTH OF LINES TpO ft <br /> 'DISTANCE TO NEAREST WELL o260 ft FOUNDATION -740 ft PROPERTY LINE 80 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 1 2 WIDTH 3 ft DEPTH ;?S ft <br /> /1 DISTANCE TO NEAREST WELL 22 1 a- ft FOUNDATION 5-0 ' 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS/PLEASE CALL 209 953-7697 <br /> SIGNED TITLE �vH R CA DATE <br /> I <br /> fA <br /> IV <br /> lR O <br /> p A <br /> 41 <br /> T <br /> PAR TMENTUS 17 ONLY <br /> Application Accepted By Date z1 Area �a Employee ID# � <br /> Final Inspection By Date 2 Z0 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Pit/Sump Soil Character: <br /> COMMENTS TI'T.4a,V. <br /> (Ji'✓�lilll-� <br /> PE SC Received heck Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By as Remitted Service Request# <br /> . <br /> 0 �.3 Gl 6 b ` 2i SI' <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />