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w <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> KION-REFUNDABLE PERMIT 7 QALL 209 9 3-7697 FOR INSPECTIONS EXPIRES 1/YEAR <br /> FROM DATE ISSUED <br /> JOB ADDRESS D CITY/ZIP /Iti J'J�J b <br /> CROSSSTREET APN �GZO�(1(Z PARCEL SIZE <br /> / l ) J b <br /> OWNER NAME jaa)�N 0(!y%d� �1 PHONE <br /> OWNER ADDRESS� S( yvtC CITY/STATEIZIP <br /> / J <br /> CONTRACTOR /lr �i�',/-AnPl�f� J/ 0 � PHONE Cj31—1 0L W <br /> CONTRACTOR ADDRESS �//py,4, 7 ��/ �1� CITYISTATE/ZIP /OZA 7� <br /> LICENSE ❑LIC-42 ❑I_IC-36 OJ HER NUMBER � EXPIRATIONDATE ���/ `2, 7 <br /> WATER TABLE DEPTH: ISS ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: C NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> Li REPLACEMENT n OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: N RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> 13 SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> CSI 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 /> z LEACH LINES ❑ LEACHING CHAMBERS / #OF LINES LENGTH OF LINES z-�/J � ) ft <br /> DISTANCE TO NEAREST WELL GG /� ft FOUNDATION %I1 ft PROPERTY LINE / , T ft <br /> ® FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> l� 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 z �� ) ft <br /> DISTANCE TO NEAREST WELL ' ft FOUNDATION l/J ft PROPERTY LINE ft <br /> T <br /> __.._.._._.___.___. <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 /> WNW&48 HOUR ADJIANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 95 -7697 n h <br /> SIGNED TITLE DATE <br /> u '.�• J A ^ <br /> 'iP F L H A <br /> EC <br /> E N <br /> DEPARTMENT USE ONLY y� / /� <br /> Application Accepted Date 9 so O Area I q / Employee ID# ��t <br /> Final Inspection By Date I I PECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMME TS 5 vis f ta' ule • xlsfin s S�eM 071 e.'ws�ln <br /> .5v S'a 1N <br /> PE SC Received he / Amount Permit/ <br /> Code INFO By Cash Remitted Date Service Request# Invoice# Permit ID# <br /> N I� !►s #3� -�0•Z� X12 00 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />