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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 PERMIJ CALL 09 53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSCITY/ZIP ,�— <br /> j <br /> �J 7` � <br /> CROSS STREET API (i0 r O Q PARCEL SIZE <br /> 0 <br /> G} <br /> OWNER NAME r-7 <br /> OWNER ADDRESS T� O r C 1 1 l�t' CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE El. C-42 ❑I IC-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: I 1 NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> I REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: C RESIDENCE ❑ COMMERCIAL _ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPL YEES: <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 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 /> MIN MUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209)9953-7697 <br /> SIGNED TITLE DATE,'> <br /> or 46i ,WIT <br /> r <br /> c <br /> ` r 'y r <br /> 4 <br /> —�1• rc_ <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date '' � Area '7 l Employee ID# �r G <br /> Final Inspection By Date C SPECIAL PERMIT-Approved by <br /> Character of Soil to Dept of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS r ce L aL� UY` <br /> ot A Co✓ Us.e_ <br /> 9 05 qou4,�o W31NAPtA ' - o ' oyt f, <br /> PE SC Received Amount Pate, Permit/ Invoice# Permit ID# <br /> Code INFO B ash RemittedService Request# <br /> o I Z 'L5 <br /> ASPeC- - L'rj.rC1,4 r�✓�� e� /mss � i <br /> 4/14/18 lr! — Q C C ry"" 1 �( f l�/ rL{ l t ONSITE WASTEWAT ]�j]Mi�T SYSTE RMIT <br /> `SANJpv `6 ?0 <br /> FH�I'�QO& 2Q <br /> NSA4ryo'P �NrY <br /> FNr <br />