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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 PE,-R+MIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ozz CITY/ZIPS <br /> CROSS STREET R�-L APN 00 7,?7 0 I PARCEL SIZE <br /> OWNER NAME PHONE C7�_ 3ZO <br /> �i<Vc/J� /CGS>DC��I � <br /> OWNER ADDRESS/ 5j1<M� _CITY/STATE/ZIP <br /> CONTRACTOR PHONE '/ / <br /> CONTRACTOR ADDRESS / 7�j, y �"� /C- CITY/STATE/ZIP y�Chw <br /> i <br /> LICENSE 11l�_42 1111C-36 OTHER NUMBER, EXPIRATION DATE 09/2:/ <br /> WATER TABLE DEPTH: ` ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: Ll NEW INSTALLATION REPAIRIADDITION I I ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: K RESIDENCE ❑ COMMERCIAL r OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG 5 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 /> S—LEACH LINES LEACHING CHAMBERS #OF LINES�_ LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL I SY> ft FOUNDATION S0 ft PROPERTY LINE %OV 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 19- WIDTH �< ft DEPTH <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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED .� TITLE fliwf�<– DATE /L o <br /> z_ eR <br /> M <br /> DEPARTMENT USE ONLY <br /> Application Accepted By –G DateZ cf j.)0 Areaz� Employee ID# DA <br /> Final Inspection By Dateh ZO ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/SumpSoil Character: <br /> COMMENTS SyS-�nv� +.1J11YF jPr Ljo ,,,ICIk Vq,f ire SPl��sc%S .pPr F t Ye("0 ( S <br /> PE SC Received Ch Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remitted Service Request# <br /> LIJI 10 1 JS 4!) '!,23-7-62- s )2 01.70 ';< ci 8 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />