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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 /�.D CITY/ZIP `•/ �/�//�N(� `'T! ���•, v <br /> y� s <br /> CROSS STREET !��j,A��itit/� APN ,O S-1 Lf Q PARCEL SIZE /V <br /> _ o <br /> OWNER NAME �(L^f-JO/ ��4 0(-1 JP `c PHONE <br /> OWNER ADDRESS 1�023 �"�U>GVl � q CITY/STATE/ZIP .zI0 he,11L i3J'6 <br /> CONTRACTOR 7- -Y /rr//1/'l/� PHONE <br /> -/ <br /> CONTRACTOR ADDRESS �;z� ��` � CITY/STATE/ZIP <br /> LICENSE ❑rC-42 111-IC-36 OTHER NUMBER �G' EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: INEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: 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 LEACHING CHAMBERS #OF LINES LENGTH OF LINES U ft <br /> DISTANCE TO NEAREST WELL/O!/ ft FOUNDATION �U 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 0— ft LENGTH ZS— ft DEPTH /1e-1 ft <br /> DISTANCE TO NEAREST WELL�ZSI> ft FOUNDATION —,)1j)-�— 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 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 /> MINIMM 48 HOQR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNE TITLE 5� ir.'�,`� DATE <br /> VC <br /> F Q <br /> N O <br /> r <br /> r <br /> EPARTMENTUSE ONLY <br /> Application Accepted By _,DDate Area l Employee ID# <br /> Final Inspection By / Date 2626 ❑ SPE IAL PERMIT-Approved by <br /> Character of Soil to Dept of 3 Ft: Pjtl ump Soil Character: <br /> COMM NTSIFruq <br /> r 7 ' r <br /> re <br /> PE SC Received Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By --Ca—sF Remitted Service Request# <br /> yd10 11s 2 300 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />