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ONSITE WASTEWATER TREATMENT SYSTEM PEROT <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 n EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Z CSI 111,el CITY/ZIP ` e <br /> / / t'y1 <br /> CROSS STREET L[` ,�� 7 �� APN �l�c/ ) PARCEL SIZE C <br /> OWNER NAME�,�L��jY/ G1 /✓G/ �J(/[/i/ 7 P.��' //s l 6 a 4 PHONE�Z��_� /�-�/ f�-7 v� <br /> OWNER ADDRESS �� w/ P CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑❑C-42 ❑❑1C'-36 OTH.E�R/1 NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: I JV ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # ' BUILDING PERMIT# LAND USE APPLICATION## <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESI NE D/AL TERN TIVE <br /> REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION <br /> INSTALLATION WILL ERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> *'SEPTIC <br /> OF LIVING UNITS: / / NUMBER OF BEDROOMS: y NUMBER OF EMPLOYEES: <br /> *r SEPTIC TANK TYPE/MFG �[�t/S (/y/ CAPACITY /i/O o 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 /> or", <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES _ LENGTH OF LINES ft <br /> ` ft <br /> DISTANCE TO NEAREST WELL�(�� ft FOUNDATION�_ft PROPERTY LINE <br /> ® FILTER BED WIDTH It 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 It 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— -3 WIDTH f ft DEPTH ' ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 1%fr ft PROPERTY LINE ft <br /> 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 4 HOUR ADVANCE NOTIGE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE {/ G{/fI/C -1 DATE Z S- z J G <br /> BIENT <br /> GE <br /> tl <br /> 5 N <br /> AwwIrAl <br /> D P T E T <br /> - 11IM11, 11 ±E <br /> VEPARTMENTIUSJ ONLY <br /> Application Accept4of <br /> Date Area "( "( Employee ID#� <br /> Final Inspection By ` Date 7i.3 [I SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth 3 Ft: Pit/Sump Soil Character: <br /> COMMzo - <br /> 0 0 i <br /> PEI SC Received heck#/ Amount Permit/ <br /> Code INFO B Cash Remitted Date Service Request# Invoice# Permit ID# <br /> lb Z <br /> 42-01r✓fit `y '`" 0S 0 wnu- 4�y A0 WR- <br /> NSITE SiT WATER TRT�PINT SYSTEM PERMIT <br /> 4/14/18 <br /> 4 l r-00v+t ko <br />