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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 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS !/ �/ 5 0( n Swl': CITY/ZIP Q 6-, <br /> CROSS STREET r'hl�l '�G� AP IN !/Z -IL)L 0 PARCEL SIZE <br /> L / c <br /> OWNER NAME t ' I..� r � �1 �'`T 7 2Z: �•�LPHOM <br /> QQ �- PHONE <br /> OWNER ADDRESS Po U c'X I 1 /71 CITY/STATE/ZIP /q���f�C`` p^ / ���� l <br /> CONTRACTOR t�A L_a,lfd (_✓I G.�1 PHONE /,6/ � }�-,�0-� <br /> CONTRACTOR ADDRESS PV lJ✓k S 1 IL 7 / q CITYISTATE/ZIP S�_A-_ VO4 <br /> LICENSE 11:.0-42 ❑I IC-36 OTHERZ I NUMBER �21��I EXPIRATION DATE �o/�� J <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I I NEW INSTALLATION REPAIR/ADDITION I IENGINEER DESIGNED/ALTERNA�-1VE <br /> 11 REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION If <br /> INSTALLATION WILL SERVE: E RESIDENCE E COMMERCIAL C 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 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH V <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE N21., <br /> ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH SAA, _ V 0 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE �, Q/i,,. V1 <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH 4N,4 H/�1� 0thb <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE °gRT4ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH �T <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 /> MINLM <br /> tolAVOUR ADVANCE NOTICE REQUIRED FOR/NSP CTIONS -PLEASE CALL 209 953-769 <br /> SIGNED TITLE bti L DATE <br /> 1 <br /> 3 <br /> 7 <br /> . y <br /> DEPARTMENT USE ONLY C%Pyo <br /> Application Accepted Date Area (Tc Employee ID# I <br /> Final Inspection By __j Date Z0 C SPECIAL PERMIT-Approved by <br /> Character of Soil to' Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS SIO -i UAl;, /c ,cy� i" L f _ L U <br /> 6+�w- k- <br /> 0) � 0 r r-M,G'1 ZL�I I 4C C�YJ�ESL <br /> (/e u rvr fv�.���i� ✓e �� ate�� <br /> PE SC ReceivedCheck# Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Bv _-C—ash Remitted Service Request# <br /> o 152- 4 •2A) M 25$ <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />