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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 11 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ao /� Po/l o CITY/ZIP J��!•�/01�1 r C <br /> CROSS STREET //� APN O �l /T�_�j� PARCEL SIZE c <br /> OWNER NAME �� AQZ. PHONE y <br /> OWNER ADDRESS -- / CITY/STATE/ZIP <br /> CONTRACTOR �'"'�yl V '` -% �/iJ/_7�J /- PHONE '?0'1 <br /> CONTRACTOR ADDRESS �7(X "w FE1L(n /t1/ CITY/STATE/ZIP � <br /> / , <br /> LICENSE ❑142 ❑CIC-36 OTHER NUMBER �/s�1��lS- EXPIRATION DATE <br /> I t <br /> WATER TABLE DEPTH:IDO _ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # I I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: CI NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> 0 REPLACEMENT U OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: KRESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: J NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG �� ��rsh^% 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 J LEACHING CHAMBERS #OF LINESl LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE _ /f 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 FOUN ATION ft PROPERTY LINE ft <br /> SUMPS �'O WIDTH (/ ft LENGTH , , <br /> C 2 1ft DEPTH ./�� t 1 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION L -- 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 ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-X7`697 <br /> SIGNED TITLE Gel�/�Gtl/� DATE off— '7—a-2 J ' <br /> e. <br /> U N <br /> A E T <br /> E ATM- <br /> PARTMENTASFIONLY <br /> Application Accepted Date Area Employee ID#.-,I!w— <br /> pp�� <br /> Final Inspection By V\,- Date ( V ❑ SPE IAL 4PERMIT-Approved by <br /> Character of Soil to D th of 3 Ft: P /Sump Soil Character: <br /> COMMENTS C�4� <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO B Cash emitted Date Servic Request# Invoice# Permit ID# <br /> V� �107 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />