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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 �D lJ C�'v� CITY/ZIP CU 1C>R <br /> CROSS STREET YaS I I T APN �01 19 O 3 3 PARCEL SIZE `/ o <br /> f " I � �l�Vie OWNER NAMEI PHONE <br /> OWNERADDRESS SIJ\\ F11�Sf S CITY/STATE/ZIP Q P) <br /> CONTRACTOR <br /> CONTRACTOR S0\\J V kLG- ' Q, '- L PHONE <br /> CONTRACTOR ADDRESS ) 'Q�h=am. U 1 CITY/STATE/ZIP <br /> LICENSE El--C-42 ❑(IC-36 OTHER NUMBER 3 JC;) EXPIRATION DATE <br /> WATER TABLE DEPTH: LI© ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT#BP" )��UJ )�lo� _ LAND USE APPLICATION# <br /> TYPE OF WORK: X NEW INSTALLATION REPAIR/ADDITION 11 ENGINEER DESIGNED/ALTERNATIVE <br /> LI REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL C OTHER n!1 <br /> NUMBER OF LIVING UNITS: (� NUMBER OF BEDROOMS: / NUMBER OF EMPLOYEES: PA <br /> .6 <br /> SEPTIC TANK TYPE/MFG 4 CAPACITY (()�V� gal #OF COMPARTMENTS r <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL tj ft FOUNDATION JO ft PROPERTY LINE �G 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 ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> C FILTER BED WIDTH 0CL1 ft LENGTH ft DEPTH q a ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 3O 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 NEAREST WELL ft FOUNDATION 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 HOU ADVANCE NOTICE RE U/RED FOR INSPECTIONS -PLEASE CALL 209 953-76917 <br /> SIGNED TITLE C'Q-�N+f A dw" DATE <br /> YA <br /> Ok-p go <br /> F / <br /> _ Ty M <br /> T <br /> DEPARTMENT USE ONLY <br /> Application Accepted B �vDate 9 e d0.2c) �,� Area 3 '1 Employee ID# <br /> Final Inspection By prE��/�4 f� Date l.�/[.� ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: �J <br /> COMMENTS /11c'--yJ a 1-rt t-b., I-A-a wa-s :2o f x 702 <br /> q'fK6•'c�. d fo �o o �T171 o ti <br /> PE SC R ceived krh #/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remitted Service Request# <br /> L-)))6 VNI S -�('SD Zfi Q �- <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />