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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 134L -14601A 1�y CITY/ZIP <br /> CROSS STREET <br /> APN— PARCEL SIZE <br /> d <br /> OWNER NAME "L*'C'y tk(' x PHONE <br /> OWNER ADDRESS kQ"Kh 94 % CITY/STATE/ZIP VVXM'Txf(-A <br /> CONTRACTORU"Tm <br /> (�y SU--w' eQ L PHONE lJ��`�^_V l�T_C �}A <br /> CONTRACTOR ADDRESS ,ORb CZ�SS�IMC2 C CITY/STATE/ZIP 11V msT-C- Q* �))� <br /> LICENSE �OC-42 ❑UC-36 OTHER NUMBER��Jt`-` EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinate X Y <br /> ❑ PERC TEST # BUILDING PERMIT# AND USE APPLICATION# <br /> TYPE OF WORK: o NEW INSTALLATION U REPAIR/ADDITION U ENGINEER DESIG�NfED IALTERNATIV <br /> _I REPLACEMENT U OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION L CtitS1'It.► T µtCf <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF,BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG { �1 1(-, r t,0'1 n� 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 R <br /> ❑ FILTER BED WIDTH N.4 ft LENGTH ft DEPTH 4-L Irl cgZ R <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 R LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH it LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R 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 /> 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-769 <br /> SIGNED TITLE A_7}1+cA-- DATE 12� "l9 <br /> iVE6 <br /> � 20yy <br /> IV <br /> �N CSU <br /> ,,N&f <br /> TMENT <br /> EP T E T E NLYbbbb <br /> Application Accepted By Date 7Area Employee ID# Da' <br /> Final Inspection By Date 7 I ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of Ft: Pit/5ump Soli Charact <br /> COMMENTS <br /> 0 ►� <br /> I <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Remitted Service Request# <br /> 0 2'3�'I6Q S <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />