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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 'I YEAR FROM DATE ISSUED <br /> JOB ADDRESS / �/� �� I�� "�`� CITY/ZIP / J S 2 U (� <br /> CROSS STREET f"\L (�Lt /f jyl �� APN J CD -2 6 Z LC PARCEL SIZE a <br /> v <br /> OWNER NAME /Ci L 4ALb✓ �� I-/✓C'^S G G PHONE r m <br /> rf <br /> OWNER ADDRESS v 3 ��— �'A��OG^(J - ±/ CITYISTATE/ZZIIP <br /> CONTRACTOR PHONE�1Ie L `1-2�/'�i C �c cJ F/ PHONE \ L U�7 7 /S-2 <br /> CONTRACTOR ADDRESS ��O / ° GCITY/STATE/ZIP /, �d <br /> LICENSE DOC-42 ❑FIC-36 OTHER _ NUMBER y,-� EXPIRATIPN DATE <br /> WATER TABLE DEPTH: Ir-SS M40 aZV 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 ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE 11 COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: I L SI 1,!-1 <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 n LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAR . WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1111 FILTER BED WIDTH s ft LENGTH / ft DEPTH ft <br /> DISTANCE TO NEAREST WELL / `7 ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOU\IDED 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 STAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 48 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE <br /> S <br /> N O Nhe <br /> Ii E L <br /> _ / l <br /> DEPARTMENJ U E ONLY <br /> Application Accepted B Date /0 70o70 Area Employee ID# <br /> Final Inspection By Date Qi \� �'7�1 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS Cormnleri10.1 /epc:lr• SXS5kevyi 1cll �ln4• ly S1ho's C' flo175 pFr, <br /> PE SC Received hec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B a h Remitted Service Request# <br /> 'Iain ds SK $ Io -Z� Zy <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />