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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 CITY/ZIP <br /> /,J/,� / <br /> CROSS STREET ---re7j�oo1 6 <br /> APN 0O-7 2 D PARCEL SIZE o <br /> z <br /> OWNER NAME PHONE p; <br /> OWNER ADDRESS -CITY/STATE/ZIP <br /> ^yte�' / <br /> CONTRACTOR PHONE P -3Y <br /> CONTRACTOR ADDRESS <br /> CITY/STATE/ZIP �/"''f <br /> LICENSE ❑�M -42 ❑UC-36 OTHER NUMBER /�/�TJ EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: C NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> F_ REPLACEMENT n OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: X (� NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG Cn/S-' 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 /> J LEACH LINES 11LEACHING CHAMBERS #OF LINES _ LENGTH OF LINES 7V ft <br /> DISTANCE TO NEAREST WELL /K/ ft FOUNDATION ft PROPERTY LINE .30 ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ,eft <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 /> \I 1 <br /> SEEPAGE PITS NUMBER WIDTH 1 ft DEPTH d^'- ft <br /> DISTANCE TO EAREST WELL /S O � ft FOUNDATION ( ft PROPERTY LINE <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 OTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 953-7697 <br /> SIGNED .- TITLE DATE <br /> to <br /> r <br /> N N <br /> Tq NTy <br /> T <br /> DEPARTMENT USE.OJYLY <br /> Application Accepted Liv crwz Date 2 Area Employee Employee ID# <br /> Final Inspection By Date 'LO20 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to D pth of 3 Ft: Pit/Sump Soil Characte�r <br /> COMMENTS SNI CJI: */1 <br /> K C <br /> 'I \; <br /> PE S Received Oleck# Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Remitted !!^^ Service Request# <br /> J _Z3714, $300 J <br /> 42-01 I ° -'`� q�2 ` `I - CC% ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 v <br />