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w <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> (VON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRE <br /> S 1 YEAR FROM <br /> DATE ISSUED <br /> JOB ADDRESS 111H <br /> /� CITY/ZIP� PA,RCELSIZEAL7DJ�^d7i {WnCROSS STREET APN LSS ZV QL� <br /> Y <br /> 0 <br /> c <br /> �� �' �� L7c� -�Sd <br /> q S - T,3111 <br /> OWNER NAME Uu�C1771�MJ PHONE <br /> �1 V1 /�� <br /> OWNERADDRESS �,3 L,S (��, ��� CITY/STATE/ZIP Mahsiv AT,, 369 <br /> CONTRACTOR M V SPS PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑EJC-42 ❑-IC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: __ NEW INSTALLATION _. REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> rl REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: 11 RESIDENCE F1 COMMERCIAL I 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 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 /> MINI UM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7�69r7 <br /> SIGNED TITLE V Jin C)` DATE <br /> O <br /> Ntr r4 <br /> E T <br /> H <br /> rD PARTMENT WSE DALY <br /> Application Accepted By DateArea 7 Employee ID# <br /> Final Inspection By Date /Zk z ��rr�� ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil tADepth of 3 Ft:` Pit/Sump Soil Character: <br /> COMMENTS <br /> 2 <br /> PE Sc Received C #/ Amount Date Permit] Invoice# Permit ID# <br /> Code INFO B Ca emitted Service Request# <br /> ` 2cA ':�YZOOI�R001 u <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />