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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 f_ /CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1/YEAR FROM DATE ISSUED <br /> JOB ADDRESS �fv(,J CJlJ /Il✓ � CITY/ZIP VLl✓pG� <br /> CROSS STREET l�/�/ /C /`--' ! "�'C�l/ APN D 1 O PARCEL SIZE <br /> O <br /> OWNER NAME PHO+N1E <br /> OWNER ADDRESS 14 Vj CITY/STATE/ZIP <br /> CONTRACTOR 0,41-q l /la kPHONE 57CONTRACTOR ADDRESS 3 / a/10 CITY/STATE/ZIP <br /> qJj <br /> y <br /> /,,A- <br /> LICENSE ❑IJ¢.:-42 ❑! iC-36 OTHER NUMBER 7�7d7 i EXPIRATION DATE <br /> WATER TABLE DEPTH: 1aU 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 /> REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: r NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG CAPACITY /,aOG gal #OF COMPARTMENTS a <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL 6eO r ft FOUNDATION 15- / 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 /> r i <br /> DISTANCE TO NEAREST WELL S_o ft FOUNDATION �� ft PROPERTY LINE A LO 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 EAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH `�� / ft DEPTH �-� f ft <br /> DISTANCE TO EAREST WELL SOL ft FOUNDATION S ft PROPERTY LINE IS- 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 488 HOUR <br /> ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED /G-�I/ ''G�f TITLE 6,UA(e"Ar, DATE 7 -4 <br /> �U <br /> cT—'= <br /> IL <br /> drid <br /> V/ C <br /> J DEPARTMENT U S E ONLY ^N <br /> Application Accepted By !� Date 7 J Area �� Employee ID# <br /> Final Inspection By Date 2� ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Dep h of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS Fc11Ufe- Z Sli'S4'm' S�ste1✓1 O/1 eX15I+h� 1v7� <br /> y <br /> PE SC Received Check Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By --Cgsh Remitted Service Re uest# <br /> Maid pis 3 20Sa ON3�Z2�'I <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />