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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 <br /> ii PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP - � <br /> CROSS STREET <br /> Z-�. y 1(�n or APN �J �� PARCEL SIZE v <br /> Ltir) _J. <br /> OWNER NAME ��Qi(A ��Ir� ! I.(/V PHONE L�� - 3 � 3 7ZL <br /> OWNER ADDRESS z 'l �l CITY/STATE/ZIP /j L// <br /> CONTRACTOR //ip1> (•/l!GG� /I ) d'i t� /yJ �(_ ' PHONE '7�JyI � z J i 7 <br /> CONTRACTOR ADDRESS _l U,�� r� �i/(/�/y �h� CITY/STATE/ZIP L- i <br /> LICENSE 0-C-42 EIEC-36 OTHER NUMBER `� n 'EXPIRATION DATE /�2— -3 <br /> WATER TABLE DEPTH: / ✓ (/ ft GEOGRAPHICAL INFOR TION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION I REPAIR/ADDITION I: ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: /NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG / Z-- CAPACITY �// /� gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL/J�)/ ft FOUNDATION �> /L ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 911 LEACH LINES I LEACHING CHAMBERS #OF LINES ) <br /> ✓v -5 LENGTH LENGTH OF LINES ,��� ft <br /> DISTANCE TO NEAREST WELL 7 ft FOUNDATION IJ l-� ft PROPERTY LINE /7� 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 S 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 /> Ml IM 48 HOUR ANC "OTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE <br /> r <br /> N <br /> M <br /> E ARTMENT USE ONLYr, r , <br /> Application Accepted y � Date Area C� Aq EmployeelD# U t r <br /> Final Inspection By Date 70 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth f 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received efi—epqo Amount Date Permit/ Invoice# Permit ID# <br /> ,C1ode INFO B Remitted,, LL Service Re ues # <br /> `t <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />