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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( 09) 9,53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ,Y C. V CITY/ZIP � /� � q r7 �(/ y <br /> G� n <br /> CROSS STREET /j/(/`/���f[_(��� APN D���10� PARCEL SIZE !1 S C <br /> OWNER NAME / /PHONE Zo // �s,�1� /�7 e,(5 7 <br /> OWNER ADDRESS ` ' CITY/STATE/ZIP ��t�/ [//y. F/ Z �C/ <br /> CONTRACTOR� �/ ,� G2�Ps 42�-�7I��� PHONE �®��� z 9 7 90 <br /> CONTRACTOR ADDRESS � X <77 CITY/STATE/ZIP <br /> LICENSE DDC-42 111-IC-36111-IC-36 OTHER C�� NUMBER r EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# ?,P-A6 LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION I REPAIR/ADDITION CI ENGINEER DESIGNED/ALTERNATIVE <br /> L REPLACEMENT G OUT-OF-SERVICE SEPTIC SYSTEM ESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL F1 OTHER <br /> NU <br /> MBERR 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 C LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 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 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 /> MINIMUM 481HOUR 46VREQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE ��� DATE �� <br /> or <br /> � J <br /> p CU <br /> ItZA 1 Ty <br /> 0 pq C <br /> DEPARTMENT USE ONLY <br /> Application AccepteB i�� Date 3 /7 Z0 ZO Area -I `� Employee ID# <br /> Final Inspection By Date S ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS SP-lIT C ln'p-i 'y-A 20y0--( wC-3 <br /> PE Sc Received Ch Amount Permit/ <br /> Code INFO B s Remitted Date Service Request# Invoice# Permit ID# <br /> yaa I 075' 4 1S-a 3.11-go 5�2 �nuZ <br /> 42-01 4-co+ 1 I Ow—t"I�1 9 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />