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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 CITY/ZIP G <br /> CROSS STREET TJ' `S APN 4 13'3 -034) C7 PARCEL SIZE i <br /> OWNER NAME LA PHONE <br /> OWNER ADDRESS l r •�V �Ji�✓. S CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑1]C-42 ❑CIC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> .J PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: L NEW INSTALLATION i I REPAIR/ADDITION i i ENGINEER DESIGNED/ALTERNATIVE) <br /> 1-1 REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION 1��/-+�s <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE 1-I COMMERCIAL ❑ 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 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 ft <br /> IvT <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH Viet)ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH $qu — F ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY klC1EI�/p-WIV (�I.— ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH h'I pA pRgR 4L 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 ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE s DATE <br /> EPARTMENT USE ONLY / <br /> Application Accepted By d Date Areaployee ID# <br /> Final Inspection By Date Ll SPE AL ZPERMIT-Approved by <br /> Character of Soil to De th f 3 Ft: it/Sump Soil Character: <br /> COMMENTS . v1 <br /> PE SC Received Check Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B sh Remitted Service Request# <br /> zz/ " 3 51;0081 a ag <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />