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't <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 (20An9,,),,953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS a. &A S!an CITY/ZIP <br /> CROSS STREET y 15�'►(/I C�l� APNPARCEL SIZE O _ <br /> 0 <br /> j a <br /> OWNER NAME� 4,/.s Del I T��� r'dt(� PHONE <br /> OWNER ADDRESS �C A C/ CITY/STATE/ZIP <br /> CONTRACTOR_ TLC 5J eC(c4 J,P i PHONE �M5b- '] sc 5 <br /> CONTRACTOR ADDRESS I 'J Y-I'V" [frJ;� (j L, CITY/STATE/ZIP Y� ►C'•���-s^�f' 5 <br /> LICENSE ❑UC-42 ❑I-1C-36 OTHER NUMBER LIP V /� EXPIRATION DATE <br /> 1 l <br /> WATER TABLE DEPTH: �� ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT#_., LAND USE APPLICATION# <br /> TYPE OF WORK: CI NEW INSTALLATION REPAIR/ADDITION Ll ENGINEER DESIGNED/ALTERNATIVE <br /> CI REPLACEMENT D OUT-OF-SERVICE SEPTIC SYSTEM I I DESTRUCTION <br /> INSTALLATION WILL SERVE: ESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: II.. 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 C LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> FILTER BED WIDTH ils/ ft LENGTH 34 ft DEPTH 19 F 1 ft <br /> DISTANCE TO NEAREST WELL 156 ft FOUNDATION � .�1 ft PROPERTY LINE IS 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 48 HOUR A VANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL 209 953-7697 <br /> SIGNED TITLE ,J f C 44-* DATE 7j.QjLb <br /> � hO <br /> A <br /> R N C U <br /> PA try <br /> q( <br /> r <br /> .DtPARTMENTIJSEIONLY ,�II ������,,// //)� <br /> Application Accepted Ald Date Area Employee ID#fir � (Yl'�GiQ <br /> Final Inspection By Date iMiolw ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 t: Pit/Sump Soil Character: <br /> COMMENTS JI� T, <br /> PE SC Receivedheck Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By UUS7h Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />