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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 n N CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1�YEEAR FROM <br /> p/DATE ISSUED <br /> JOB ADDRESS ,` p� L���Gr CITY/ZIP S �N (�/I J/l�L�(r�// Z <br /> CROSS STREET W&6Az/'9 ft`�� �I APN /6-1 _ O�y 13 /7�PCAJRCELSIZFZ��S/1`r�`� <br /> OWNERNAME :LoAk) Bo-y- <br /> (� / �P ON®(.(J/_ �/�I//�/` ` 77,6 <br /> OWNER ADDRESS l i (/, C Jlo-y- a/ CITY/STATE/ZIP`�Gcn- �eFrrd l/// 67��1 / <br /> CONTRACTOR \J L�I/i G'� PHONE 61 I e- <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑; C-42 Eli;C-36 OTHER NUMBER EXPIRATION DATE <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 I I ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM )( DESTRUCTION SP )l !L ll <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <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 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 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH , ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINES <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH F qQU/ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE LTN n MNy <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH <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 /> MINIM"48 KWR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 90-7691- <br /> SIGNED TITLE DATE —� <br /> r <br /> DEPARTMENRUS ONLY <br /> Application Accepted B Date 090 Area J Employee ID# <br /> Final Inspection By _ Date 2 2t E SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <-OW cl - be <br /> T— <br /> PE Sc Receivedhe Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash RemittedService Request# <br /> `laa ► 075- 0 41E2 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />