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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)9n ��/►53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �(1 p lnoc" ro CITY/ZIP Y ► ct <br /> CROSS STREET vh y� S`1' APN o I� PARCEL SIZE p <br /> C <br /> ^� [, <br /> OWNER NAME _� Ai e-5 PHONE <br /> OWNER ADDRESS i CITY/STATE/ZIP <br /> CONTRACTOR �' �� !TG/C jt 'moi �J PHONE w 51'a r►� �j�j,� <br /> CONTRACTOR ADDRESS P K�`1A hr's CITY/STATE/ZIP f111G=+►u:.e� I C.tt- f �C <br /> LICENSE ❑❑C-42 ❑LIC-36 OTHER (r� NUMBER —` EXPIRATION DATE ,inaz <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: Is 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 /> _ ft <br /> DISTANCE TO NEAREST �dCtF-i-+a� n ruuivur i ivry �� ,i rte-- ft <br /> FILTER BED WIDTH ) 2- ft LENGTH ZU ft DEPTH 3�► 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 <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 <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 HQUU ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE Cn \ t fGc'I V(- DATE� ( o-'640 <br /> v <br /> 0 <br /> � O O <br /> J�l/J DEPARTMENT USg ONLY <br /> Application Accepted B Date Area 3 q Employee ID# <br /> Final Inspection By Date4!5ZOZO ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Che Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> q;?16 l 3da -it-20 5a -zi'qos <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />