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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 T% S 17.1 P-o CITY/ZIP <br /> CROSS STREET APN oo70`1013 PARCEL SIZE S�' <br /> v <br /> o <br /> OWNER NAME / r x <br /> n PHONE 1 <br /> OWNER ADDRESS n(�J 3 L• , c I F V R l CITY/STATE/ZIP A(CTIM a,) CA o v <br /> CONTRACTOR Cl 4/u/ ►n/fie(llid //J�A'G PHONE ^�3��j//� �C,/l/3�7 <br /> CONTRACTOR ADDRESS _/ (� 1"c LJ^yH „w ///� CITY/STATE/ZIP <br /> LICENSE 111 f42 11-IC-36 OTHER NUMBER �EXPIRAT10NDATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION Y REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE I I COMMERCIAL I OTHER <br /> NUMBER OF LIVING UNITS: .J-- NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG fyI'Sj,'j 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 /> i!� <br /> LEACH LINES LEACHING CHAMBERS #OF LINES � LENGTH OF LINES /T ft <br /> DISTANCE TO NEAREST WELL �o t ft FOUNDATION Y ft PROPERTY LINE (Da 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 v WIDTH 3 /til ``JJ ft DEPTH ft <br /> DISTANCE TO NEAREST WELL- S`O / ft FOUNDATION 7e / ft PROPERTY LINE l00/ 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 6 /L i DATE <br /> r <br /> IV <br /> 0 <br /> R <br /> A <br /> F <br /> T DEPARTMENT USE,ONLY <br /> Application Accepted By C Date -?1,WS-1Z0Z0 Area %% Employee ID#_, t�� <br /> Final Inspection By Date El SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of Ft: Pi Sump Soil Character: <br /> COMMENTS Al <br /> G� less vrl rP.i�r • <br /> PE SC Received heck#/ Amount ate Permit/ Invoice# Permit ID# <br /> Code INFO B s Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />