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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 O S Li CITY/ZIP x-4- �d n/ 0 v <br /> :j <br /> CROSS STREET t. APN p, 3 3 —004: PARCEL SIZE p <br /> O <br /> OWNER NAME Z PHONE <br /> OWNER ADDRESSw��Tf 1�U C CITY/STATE/ZIP <br /> /� T <br /> CONTRACTOR i - Z d 4 /N�o_ D '-(1166 PHONE <br /> CONTRACTOR ADDRES 1 v` v / CITY/STATE/ZIP L OK <br /> LICENSE ❑OC-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 ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT C: OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: 11>�ESIDENCE 11 COMMERCIAL Ff 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 /> 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 /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT 1 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 /> MINI UM 48 H UR ADVANCE NOTICE REQUIRED FOR INSP CTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE <br /> _ <br /> i----.--- 9(11N CC U <br /> _ I <br /> DEPARTMENT USE NLY <br /> Application Accepted 13y Date Area mployee ID# <br /> Final Inspection By Date ❑ SPE IAL PERMIT-Approved by <br /> Character of Soil to Dept of 3 Ft: PiUS mp Soil Character: <br /> COMMENTS tea. ..v _C r 74 L., <br /> PE SC Received Check#/ Amount Permit/Code INFO B Cash Remitted Date Service Request# Invoice# Permit ID# <br /> Z S2— JW SR 008 137 7 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />