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j f <br /> 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 209 953-7897 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS Y CITYIZIP <br /> CROSS STREET APN [/� O PARCEEL SIM �p7 <br /> OWNER NAME PHONE I�D I—57, —7�A"'Yt' Pi's L/ny <br /> 47 <br /> OWNER ADDRESS CITYISTATEIZIP AjM4 <br /> CONTRACTOR PHON L ((( <br /> CONTRACTOR ADDRESS CRY/STATE/ZIP <br /> LICENSE C-42 C-36 OTHER NUMBER EIPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> 1-1 PERC TEST # BUILDI # 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 V OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPEIMFG (/ CAPACITY I L—G� ✓ gal #OF COMPARTMENTS_ <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTSS <br /> � �, <br /> DISTANCE TD NEAREST: WELL 7--AS-IrlftFOUNDATION_ II ft PROPERTY LINE �—0 ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKGTXPLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES LEACHING CHAMBERS #OF LINErrr--5777� LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE T ft <br /> ❑ FILTER BED WIDTH it LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH it 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 it PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WALL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIJULJIQ� <br /> � R VANYANCE NOTICE REQUIRED FOR INSPECTIONS-!PLEASE CALL 209 953-769 <br /> `r <br /> SIGNED TITLE 4 kd. DATE <br /> -a i irA <br /> ENT <br /> VSD <br /> 2019 <br /> O ouHn, <br /> P TAL <br /> MENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted Date Area Employee ID#�� <br /> Final Inspection By Data It f� I�7,ot4 ❑ SPECIAL PE IT-AAproved by <br /> Character of Soil to of Ft: D it/Sump Soil Character: �(,/%' <br /> COMMENTS �/`� <br /> v""/ <br /> PE SC Received eck#I Amount Date Permit/ Invoice# PermitID# <br /> Code INFO B ash Remi rvice R uest# <br /> fVar vi 5w 111116Ig ISg <br /> 42-01 I4� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4114118 VHV <br />