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ti <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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS 2 577 / C�Ofipl"t CITY/ZIP A4 �7iLJ v <br /> CROSS STREET �•r� t3 v T APN Q 0 7—2Z O' / PARCEL SIZE y <br /> OWNER NAMECU< 'f� E'mS��'- PHONE G'6 <br /> OWNER ADDRESS '7KIV!li CITY/STATE/ZIP <br /> Tr <br /> CONTRACTOR�P_J'J/Kl7L 1 lC/ /�y PHONE 76LSZ/7/ <br /> CONTRACTOR ADDRESS / y4cw,,C/ 'f' z7""'xL y7iC CITY/STATE/ZIP <br /> LICENSE ❑r<C-42 ❑L.0-36 OTHER NUMBER ySrICJ`�S EXPIRATION DATE <br /> WATER TABLE DEPTH: l7L), ' ( ��r ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: L NEW INSTALLATION X, REPAIR/ADDITION L: ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: J NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG �Xi S/�w�, CAPACITY /0610 gal #OF COMPARTMENTSy <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 F LEACHING CHAMBERS #OF LINES LENGTH OF LINES U ft <br /> DISTANCE TO NEAREST WELL ftX% ft FOUNDATION ft PROPERTY LINE `jU 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 -36 jI ft DEPTH ��� ft <br /> DISTANCE TO NEAREST WELL �� ft FOUNDATION /!/- ft PROPERTY LINE Sy ft <br /> 1 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 53-7697 <br /> SIGNED �1 �— TITLE DATE <br /> N / C UPITV <br /> T p P A <br /> D PARTMENT LJSEjONLY <br /> Application Accepted By Date / Area Employee ID#� <br /> Final Inspection By d Date -ZOO ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS �� <br /> PE SC Received &j1eaW Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remitted Service Request# <br /> S 12a P\00 17 5& <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />