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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 CA L(209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �� J h �` CITY/ZIP�j�/l OjAA _ <br /> CROSS STREET /�►�(lO��Q�/ ,/C,l`, APN_ S 6 D (S� PARCEL SIZE <br /> 0 <br /> OWNER NAME PHONE <br /> OWNER ADDRESS S C• / �t IS /L1�/(' CITY/STATE/ZIP <br /> CONTRACTOR 1 �" PHONE <br /> CONTRACTOR ADDRESS Cf / CITY/STATE/ZIP S G 3z ­� <br /> � /n <br /> LICENSE ❑[-C-42 Ell-IC-36a <br /> I-IC-36 OTHER NUMBER l/�� EXPIRATION DATE a _::z/ <br /> lyU' <br /> WATER TABLE DEPTH: v O ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# 00 0a RFS LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT i OUT-OF-SERVICE SEPTIC SYSTEM i DESTRUCTION <br /> INSTALLATION WILL SERVE: ESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: / f NUMBER OF BEDROOMS: / NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG �a' L CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY ` gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL' ft FOUNDATION J / ft PROPERTY LINE f f <br /> , 7� ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ,ML-LEACH LINES I LEACHING CHAMBERS #OF LINES f LENGTH OF LINES d�S� ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ��f 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 SNE ft <br /> 'WLSEEPAGE PITS NUMBER _::� WIDTH ft DEPTH 2 ft <br /> DISTANCE TO NEAREST WELL /y� y ft FOUNDATION �<, 7 ft PROPERTY LINE -5/ T 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 HOUR A NC TICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE'// %=,Z� <br /> q <br /> F Q <br /> +HO <br /> q <br /> DEPARTMENT USE ONLY <br /> Application Accepted �Z_ Date II 0/9')d-", Area �� Employee ID# <br /> Final Inspection By_L&9_ ;� Date Za ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS SF(Z. J_ler- 1C 1 i, .-Jell ,j; rl%In sej44'�- 2ef un1�1 )'etofds <br /> PE Sc Received heck# Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash Remitted Service Request# <br /> ya ► )-7 •Zo <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />