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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 09 9.53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS W ALT 7• CITY/ZIP , s <br /> J 7 <br /> CROSS STREET LC'III i^'1(i� APN�- J y(j ' o� PARCEL SIZE <br /> OWNER NAME_ 1 PHONE <br /> _ � 7 <br /> —7?5`L <br /> UJ <br /> OWNER ADDRESS <br /> Ck <br /> CONTRACTOR (�� � ,•`L� 1s17 �,�j .�.C`C-� ►�` PHONE Z;J�� �y'- `44z� <br /> CONTRACTOR ADDRESS �G7 ✓� ��•S �� CITY/STATE/ZIP <br /> LICENSE ❑I IC-42 111IC-36 OTHER ` NUMBE (I. III0(f EXPIRATION DATEZ C� Z <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 DESIG,N/ED/ALTERNATIVE f <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION C,eStr U<l 1 J n kt111 <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> JA NUMBER OF LIVING LRITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC T 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209)953-7697 <br /> SIGNED TIT S`<<1 DATE '7 Z� Z✓ <br /> e <br /> 01 <br /> .10 <br /> 1 <br /> NT <br /> � ED <br /> 111A 0 <br /> /yr, <br /> IRTMEN USE ONLY EPARTME <br /> Application Accepted By % 1�_ Date 7 4 -7 v Area s Employee ID# /. IVT <br /> b .Z Zd C SPECIAL PERMIT <br /> Final Inspection By �)-.� _ Date� -Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS douse 6vi led. -{o b,: Ityan,,wd <br /> PE SC Received ck# Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash Remitted Service Request <br /> # <br /> �Jd� u 1 S lg 2 J.il S1�lC5T- l <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />