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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 1CITY/ZIP ,5400 94 9 .5 tel_Off/ <br /> U <br /> CROSS STREET U/�/ APN 1���V�O f PARCEL SIZE - i t, <br /> QQ O <br /> OWNER NAME k el a z PHONE Zol t l2 - -I(�l? g <br /> OWNER ADDRESS / CITY/STATE/ZIP 04 C s a 4 <br /> CONTRACTOR �//�(�(/� PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 1-I1 !C-42 [1: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: L NEW INSTALLATION REPAIR/ADDITION I : ENGINEER DESIG ED/ALTERNATI <br /> I REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: EJ RESIDENCE ❑ COMMERCIAL L OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 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 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 t,5Z-_ )Tt <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINEA ft <br /> El SUMPS WIDTH ft LENGTH ft DEPTH r ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY L U 1, Q ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH HF..�RD�n,. ft <br /> _ _ <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINN�E��/�� FA -`�/V�_ ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH MENr 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 HOUR ADV NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 9553-7697 <br /> SIGNED TITLE G�(CJx� DATE <br /> EPARTMENT SE O LY <br /> Application Accepted Date Area -` l Employee ID# <br /> Final Inspection By Date Y012 Q IJ SPECIAL PERMIT-Approved by <br /> Character of Soil to D pth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> ti► bale, I <br /> v D ` rtum� ftzr - <br /> PE SC Received - heck Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Remitted Service Request# <br /> 2 . 5?001&1 ao a <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />