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ONSF E WASTEWATER T REATMENIF SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT ���11 CALL209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS q1q0 �t�l �(��► C CITY/ZIP C O• S <br /> CROSS STREET \ �j G 25'izte APN O v1�7�-+ 01 PARCEL SIZC- a 7 d <br /> OWNER NAME JoSPp� 115Fr PHONE <br /> OWNER ADDRESS V✓I 'CITY/STATE/ZIP <br /> CONTRACTOR �ljy A PHONE <br /> CONTRACTOR ADDRESS lX �J. -C�lc /,"[ CITYISTATE/ZIP �C k '/ '"11 `(�'� <br /> LICENSE Ilk <br /> C-42 ❑❑ � <br /> C-36 OTHER NUMBER / 9oV-�EXPIRATION DATE <br /> WATER TABLE DEPTH: IOb ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT## LAND USE APPLICATION#I <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: J/ NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> Q 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 ( a ft <br /> r � t <br /> DISTANCE TO NEAREST WELL ft FOUNDATION /D ft PROPERTY LINE 30 ft <br /> L7i FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> E2 MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> F-71 SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> C.: DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER WIDTH r ft DEPTH d ft <br /> DISTANCE TO EAREST WELL_//0 T ft FOUNDATION _56 ft PROPERTY LINE /0 � 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS/-PLEASE CALL (209)953-/7697 <br /> SIGNED - TITLE �� rl1l/71 DATE <br /> A U/ <br /> T N <br /> DEPARTMENT USE ONLY u �//pry TMENT p <br /> Application Accepted By G� Date It o Area I 7 / Employee ID#�D/ <br /> Final Inspection By Date lI I Z /Z ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Dept f 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS SvserVt f'c��lure. E��> rY,� �o� s eX►s�iYtti sy4-f�eyh <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remitted ervice Request# <br /> aia IS sic 0 it�u6­01 m2wv) <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />