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1 <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 \ � � � �\ -CTrv/ZIP v' <br /> CROSS STREET �7 1�1 -+ 117- APN'nD LJ�'D �� l (�P CEL SIZE g <br /> OWNER NAME _O 1`�lJ 1' IC��S f�tS IZ � t�..� PHONE <br /> OWNER ADDRESS I`1 2n-2- <br /> l� `A- I�l.�l�1 /'1,. CITY/STATEMP I - Or-,-2-1CONTRACTOR '1' 1'��� 5�'D �`(a�� 1�Jl7 G9-Vkh1)E.- PHONE :7ks-4 <br /> CONTRACTOR ADDRESSCT^^ p <br /> CITY/STATEZP �' 1z7,L.5� • Q5'� � <br /> S <br /> LICENSE Ll C-42 LWC-36 OTHER 1��2- NUMBERr9L-1 I 1 tP PIRATION DATE t'L�� ZOL 'N <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# 77-71 <br /> TYPE OF WORK: New INSTALLATION REPAIR/ADomoN ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM 0 DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE LI COMMERCIAL LJ 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 /> ❑ 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 ft <br /> ❑ FILTER BED WIDTH ft LENGTH it DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ SUMPS WIDTH R LENGTH it DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION It PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH it LENGTH ft DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ SEEPAGE PITS NUMBER WIDTH it 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 /> MMUM 48 HOUR ADYAt(CENOTICE IR D FOR INSPECTIONS ISE953-7697 <br /> SIGNED TITLE RJ-S�;GT \•11��? - DATE �� �� t <br /> A ��A Y <br /> C <br /> VE® <br /> 3 0 2018 <br /> QUIN COUNTY 7Y <br /> DEPARTMENT <br /> DE ARTMENT YSEO <br /> Application Accepted By Date Area Employee ID#j�� <br /> Final Inspection By Date ❑ SP IAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS U - - W- I r <br /> PE SC Received hec Amount Date PerrniY Invoice# Permit 10# <br /> Code INFO By_ ash Remitted Service Re ueSt# <br /> Z ' U <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />