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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( IF <br /> CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1 2-V3 J 6G C9 7-)eA 6)2JAJ Li 'rQ CITY/ZIP <br /> / //aJ� 7 <br /> CROSS STREET ��/ br�/�/,� APN v Z �D C�� PARCEL SIZE <br /> OWNER NAME /�/(7�J�j =+�^�.� PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR A�O�(ti.g� v e �L —�L�F� PHONE( 2,,­- ) <br /> CONTRACTOR ADDRESS J I//O t/ �P/N✓{�J LCITY/STATE/ZIP f'��✓, G y S j S <br /> LICENSE ❑❑C-42 ❑CIC-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 41! REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: 'A RESIDENCE ❑ 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 W LEACHING CHAMBERS #OF LINES r/' / <br /> LENGTH OF LINES 74> ft <br /> DISTANCE TO NEAREST WELL / �� ft FOUNDATION O 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 3 ft DEPTH r ft <br /> DISTANCE TO NEAREST WELL Z ft FOUNDATION y 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 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIIO-NSI- PLEASE CALL 209 953-7697 <br /> SIGNED TITLE t>�-/�� Z�� DATE 3 <br /> Nr <br /> � ED <br /> 0 <br /> Q <br /> 20 <br /> N E NTY <br /> RM T <br /> EPARTMENTUS ONLY <br /> Application Accepte4Qeth93 <br /> Date Area Employee ID# <br /> Final Inspection By Date 3 ❑ SPECIAL PERMIT-Approved by <br /> IV V <br /> Character of Soil to Frt:� Pit/Sump Soil Character: <br /> COMMENTS If C g� CeY�LQ �'► <br /> u � <br /> PE SC Received hec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B sh Remitted Service Re uest# <br /> Zu - <br /> 3 9ROD 106 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />