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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 c-23 � oGh CITY/ZIP 0 <br /> CROSS STREET �/N�'!� �d APN O7d 7 O J PARCEL SIZE <br /> l� p <br /> •. -, iQc,Sl c��«- �t�;rem J�vie, W 0 I <br /> OWNER NAME lI lPHONE �` N <br /> OWNER ADDRESS SOD9 SnN+G, I'�4r4- ICaC"�c, Dr CITY/STATE/ZIP /�L)�j/-OS /�/( <br /> CONTRACTOR �� PHONE <br /> CONTRACTOR ADDRESS LlvtC CITY/STATE/ZIP <br /> LICENSE ❑ -42 ❑LIC-36 OTHER NUMBER ��t% EXPIRATION DATE <br /> WATER TABL((((((E OX-42 <br /> 1 S � ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# p1 O=0O LAND USE APPLICATION# <br /> TYPE OF WORK: /� NEW INSTALLATION !IREPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ` C REPLACEMENT n OUT-OF-SERVICE SEPTIC SYSTEM Cl DESTRUCTION <br /> INSTALLATION WILL SERVE: X RESIDENCE ❑ COMMERCIAL /� ❑ OTHER <br /> NUMBER OF LIVING UNITS: //j // NUMBER OF BEDROOMS: Y- NUMBER OF EMPLOYEES: <br /> ( SEPTIC TANK TYPE/MFG CAPACITY 16,01/7 gal #OF COMPARTMENTS_ <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL v�4 j ft FOUNDATION s ft PROPERTY LINE COd ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP Cl PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES 3 ) LENGTH OF LINES �S ' ft <br /> i <br /> DISTANCE TO NEAREST WELL o^w�a/ ft FOUNDATION 0 t ft PROPERTY LINE 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 LINE ft <br /> SEEPAGE PITS NUMBER WIDTH !� ft DEPTH , ft <br /> DISTANCE TO AREST WELL �bO ''- ft FOUNDATION &0 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -//PLEASE CALL (209)953-7697 <br /> SIGNED TITLE ��77f�1/LJ'�'" DATE /d -/S -a�✓ <br /> u <br /> N U <br /> F <br /> F <br /> DEPARTMENT,USfF ONLY �1 /� <br /> Application Accepted By —� Date ?D (D Area '1 "/ Employee ID#�r <br /> Final Inspection By Date [ ( _ZO ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to D h of 3 iFt Pit/Sump Soil Character: <br /> COMMENTS 0- .r In } areas per nourfy 'rP";0'rdr <br /> PE Sc Received C eck Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By — sjk Remitted Service Request# <br /> a i I 117 8I i0 ►5 21� 00 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />