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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 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 3 v.A r A, CITY/ZIP t*—*' .fi- `0 7 Lon <br /> CROSS STREET M/ r����/�'y APN 1q-3 /YV O2— PARCEL SIZE � b <br /> OWNER NAME lT�G IV l�M" / a 6" 1 Lc/iC/I/A PHONE �h <br /> OWNER ADDRESS ^ ,�1 CITY/STATE/ZIP <br /> CONTRACTOR / � S e) r" t PHONE per((J C7 ( _�� <br /> CONTRACTOR ADDRESS 1/0 1 2 774 st CITY/STATE/Z P / <br /> Q Llf-- 9 ^ <br /> LICENSE ❑f]C-42 LII-IC-36 OTHER NUMBERMO EXPIRATION DATE <br /> WATER TABLE DEPTH:l 61 � y It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION LI REPAIR/ADDITION L ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT 0 OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL /A- ❑ OTHER <br /> ( <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: (/ NUMBER OF EMPLOYEES: <br /> ® SEPTIC TANK TYPE/MFG CAPACITY r� gal #OF COMPARTMENTS _ <br /> El GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> r//��V <br /> DISTANCE TO NEAREST: WELL � 't It FOUNDATION fi ft PROPERTY LINE ft <br /> LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> E3 LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL - ft FOUNDATION It PROPERTY LINE ft <br /> FILTER BED WIDTH 1,0 ft LENGTH 4--0 ft DEPTH"I�" ^Oat( ft <br /> ho 1187- DISTANCE TO NEAREST WELL_ I� ft FOUNDATION ft PROPERTY LINE S 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 /> 0 SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY T VE 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 /> INIMU ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE L' DATE <br /> —4z e7clyj M_ <br /> E T L <br /> N <br /> o rA <br /> r <br /> B PARTMENTIJSEbNLY <br /> Application Accepted B Date ! Area Employee ID# <br /> Final Inspection By Date_ SPECIAL PERMIT-Approved by < <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Cl aracter: <br /> COMMENTS O -two 0111+ � 3 S <br /> sen <br /> PE SC Received Ch Amount 6ate Permit/ Invoice# Permit ID# <br /> Code INFO By ash Remitte Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />