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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 193 7 CITY/ZIPLA <br /> _ -� 1�, <br /> CROSS STREET tAc APN [,3 a o PARCEL SIZE t3:5 'y <br /> OWNERNAME 1�-LJ tJrCT�fp'�l PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP 1 j, (( 4A CX <br /> CONTRACTOR y '�{ i PHONE u`) '?-Y6 <br /> V <br /> CONTRACTOR ADDRESS \�J� `"Y N�Y��IN .r r CITY/STATE/ZIP % (f (a <br /> LICENSE ❑ :C-42 ❑IlC-36 OTHER 6r#.� D NUMBER 'IOW EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I I NEW INSTALLATION REPAIR/ADDITION I I. ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I I DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL L OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: q 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 /> C('\.' <br /> ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES W ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE f 5 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 It <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 /> 8 OUR ADV N E NOTICE REQUIRED FOR INSPE <br /> ��C <br /> ,n,TI,,ONS -PLEASE CALL 209 953-7697 <br /> SIGNED TITLE 9,MX^^ ciCTI DATE <br /> 0 <br /> y , 0 <br /> H <br /> DEPARTMENT USE ONLY <br /> Application Accepted B Date 11 3 aUao Area �� I Employee ID# N l7 <br /> Final Inspection By c Date Z V C SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS Aad l h'Do 6C C, 6ed/00rn cyvlC) repla(-inG one hvle Imp4derj Lx ne ;S <br /> bL'Inc arc �rclone �o� c�oSe str vft cP LlkO)� - lot 0 &? -r t e 4 <br /> PE SC Received Ch k#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By ash Remitted Service Request# <br /> L)alo �►s3� 3. <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />