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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 i 1 -F-r, `r J. CITY/ZIP <br /> CROSS STREET APN <br /> PARCEL SIZE <br /> C <br /> A � z <br /> OWNER NAMEZ�I� �i G�, 4 L`�tX G � C.�'/Py`7�'f'1� �� 1 PHONE D � C�� I <br /> OWNER ADDRESS �cttM� CITY/STATE/ZIP <br /> CONTRACTOR I/r I i IL"-i5 JCS'gPHONE <br /> CONTRACTOR ADDRESS f d acsx CITY/STATE/ZIP A ✓a G <br /> LICENSE ❑i_C-42 ❑ C-36 OTHER NUMBER EXPIRATION DATE <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 I ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION <br /> INSTALLATION WILL SERVE: Ui ESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: ( NUMBER OF BEDROOMS: 3 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 /> LEACH LINES I LEACHING CHAMBERS #OF LINES LENGTH OF LINES L10i ft <br /> 3 <br /> DISTANCE TO NEAREST WELL) ft FOUNDATION Lo ft PROPERTY LINE (�7 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 /> 01 SEEPAGE PITS NUMBER WIDTH 3(. rl ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ' t;- ` ft FOUNDATION ft PROPERTY LINE 16 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 20 953-7697 <br /> SIGNED TITLE C /1414c+(SC DATE <br /> J ,q <br /> U <br /> P A( <br /> T <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Z& w zip Area Employee ID# ✓ `'N <br /> Final Inspection By - Date ZV20 11 SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTSLlyl /-rxl1'✓� <br /> 1A I <br /> PE SC ReceivedChec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />