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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 G J /� CITY/ZIP O <br /> CROSS STREET / GS /� f}(ii� . APN___ y O tk�n PARCEL SIZE L/ <br /> OWNER NAME U C�1 /}1 _ _PHONE S6 <br /> OWNER ADDRESS 1 / GV4 CITY/STATE/ZIP <br /> CONTRACTOR.. /�((/�-Q s t'�� s �G�a/L PHONE s­-7 <br /> CONTRACTOR ADDRESS / /"o ��/�U�/ �' y� (J/� CITY/STATE/ZIP ��� yI• J�J S� <br /> LICENSE ❑❑C-42 ❑❑C-36 OTHER NUMBEREXPIRATION DATE 7�Z 30/ 2- <br /> WATER <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION 0 REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: 4F 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 /> D LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ® LEACH LINES ❑ LEACHING CHAMBERS #OF LINES�_ LENGTH OF LINES 7 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION /C, ft PROPERTY LINE 3 , 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 It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER Z WIDTH 3 ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION /Cil ft PROPERTY LINE S 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 /> MINIMUMAN HOUR ADVANCE NOTICE REQUIRED FOR IN PECTIONS- PLEASE CAL 209 953-7697 <br /> SIGNED TITLE �� ��� DATE 3" Z-� Z 0 <br /> IiA <br /> O <br /> /1 O 'Afjy <br /> EPARTMENT USE ONLY G� <br /> Application Accepted B Date Z Area 1 Employee ID# <br /> Final Inspection By Date 3 ' ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Charact <br /> COMM NTS "' AID <br /> U►/\ <br /> CCG 6c tr <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cas Remitte Service Request <br /> �7 + 2- 3 3• ; ZD JY� c� <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />