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s <br /> 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 ^ /I CITY/ZIP C <br /> H <br /> t+7 <br /> CROSS STREET 1 a reAPN O O PARCEL SIZE � I <br /> l� r�7 hf <br /> OWNER NAME \ PHONE 3.�J'` rn <br /> OWNER ADDRESS $_– CITY/STATE/ZIP rr! <br /> CONTRACTOR �(Il,c,� G4�1.. 1�' PHONE 1`,Cy` �yCvS <br /> CONTRACTOR ADDRESS /� F��C (y�D —CITY/STATE/ZIP ��l,�vlLu¢ <br /> LICENSE ❑LIC-42 ❑UC-36 OTHER 1/V NUMBER Z> EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMTION: C rdinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# AND USE APPLICATION# <br /> TYPE OF WORK: C' ,.WW INSTALLATION REP URIADDITION ❑ f NGINEER DESIGNED//ALTERNATIVE <br /> REPLACEMENT n OUT-OF-SERVICE SEPTIC SYSTEM ial DESTRUCTION r <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: Ll NUMBER OF EMPLOYEES: <br /> Q- SEPTIC TANK TYPE/MFG f d CAPACITY gal #OF COMPARTMENTS !� <br /> ❑ GREASE TRAP TYPE/MFG i CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE To NEAREST: WELL i o I ft FOUNDATION 1f 1 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 LINES1 LENGTH OF LINES I an I ft <br /> DISTANCE TO NEAREST WELL I / ft FOUNDATION 3S I ft PROPERTY LINE r 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE /'' r� ®� DATE J �j'-7 r,-6 3-G <br /> VC <br /> E Q <br /> TY M <br /> R � <br /> DEPARTMENTUSE O LY <br /> Application Accepted By Date z Area Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pi Sump Soil`Ch-j'racter: <br /> COMMENTS XlLtI Xd ._ I'&z;"A S , 011 +0 �I (% <br /> PE SC Received C Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service a uest# <br /> z f yl <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />