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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 yj— CITY/ZIP Ci <br /> a <br /> CROSS STREET / �� I APN Z'/ ��(O b ! PARCEL SIZE f o <br /> OWNER NAME / hl t /' C�CJ�/��'y1 N�A 5 PHONE y <br /> OWNER ADDRESS �+ CITY/STATE/ZIP <br /> CONTRACTOR A;Re o`c +' k �G�� PHONE <br /> CONTRACTOR ADDRESS /4-11-11) / f� '4 41-11 6141- CITY/STATE/ZIP "o-lo <br /> LICENSE [1IC-42 ❑1 C-36 OTHER / NUMBER / Y� EXPIRATION DATE <br /> WATER TABLE DEPTH: ! ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: i NEW INSTALLATION1. , r L i REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> S�^ REPLACEMENT lmNK b.,x h 6ed❑ OUT-OF-SERVICE SEPTIC SYSTEM V DESTRUCTION tr4"k <br /> INSTALLATION WILL SERVE: Fr RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: -�3 / NUMBER OF EMPLOYEES: <br /> El SEPTIC TANK TYPE/MFG �L � �� �L CAPACITY �yGJ gal #OF COMPARTMENTS 211 <br /> ❑ GREASE TRAP TYPE/MFG / CAPACITY / gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL l c� ft FOUNDATION C d w ft PROPERTY LINE ��� ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ® LEACH LINES 1-1 LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION f� , ft PROPERTY LINE S ft <br /> ❑ FILTER BED WIDTH It LENGTH It 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 It <br /> ® SUMPS a WIDTH q ft LENGTH 2- 41 . <br /> ft DEPTH ls� _ ft <br /> DISTANCE TO NEAREST WELL /Z 0 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 1HE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM HOUR ADVANCE NOTICE REQUIRED FOR WSPE TION <br /> S - PLEASE CALL 209 953-7697 <br /> SIGNED f� TITLE .� '�'"� DATE <br /> J <br /> DEPARTMEN U E ONLY EP,gRTME T <br /> Application Acceptedy �� Date 7 /S0,;10�J1Area S Employee ID# k. <br /> Final Inspection By l� .Z,7Vk k lam' Date [m ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to l5epth of 3 Ft: it IS Soil Character: SQIYIf <br /> COMMENTS ���Ure of Salem, Tierr rnS12tvivr W1usf be nble ioye, the 3 Y,-pe Zsui o»U <br /> t6jf it is aeCJUO}e & r--' lftiCll I<%eldlO1- n-r'Pased cw IpJ�h. LkIs4( sy54eYn Jn eX'15Nn6 10�, <br /> PE SC Received heck#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Bv Remitted Service Request# <br /> LQ)a '?DO 1-1570 2 Z <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />