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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 e� ' >��1� CI/TY/ZIP CJ n'r' y v <br /> CROSS STREET J� �/}�//u/ APN 0 �� h� PARCEL SIZE J <br /> OWNER NAME z& PHONE <br /> OWNER ADDRESS SGI Vy CITY/STATE/ZIP <br /> �J <br /> CONTRACTOR /� � L/� iy�/I� ic'i PHONE <br /> CONTRACTOR ADDRESS �/+ � �� CITY/STATE/ZIP <br /> LICENSE ❑, C-42 11CIC-36 OTHER—4 4 NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: 5 160 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 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 <br /> T' <br /> DISTANCE To NEAREST WELL­2,2ZI.12L ft FOUNDATION �!% f L' ft PROPERTY LINE <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 S ft DEPTH �`' -S l ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION T/J ft PROPERTY LINE S TL 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 /> MINI 48 HOUR VA E NOTICE REQUIRED FOR INSPECTIO_N�SJ�- PLEASE CALL 209 953-7697 �) <br /> SIGNED TITLE ��/ DATE L/ <br /> NJ <br /> U ' ) <br /> 0 <br /> Nr 1 <br /> � R i <br /> S , <br /> J <br /> T C <br /> DEPARTMENT USE ONLY <br /> Application Accepted B.V Date II �� J Area Employee ID# D� <br /> Final Inspection By Date wV PECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS bk f �� �Q. i�l J ,I S �' ���111� ,;-- f �i ' <br /> PE SC Rkeived (the / Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By ash Remitted 11 Service Request# <br /> �I�►� pis -�3�� ii � S <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />