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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 Iq /ExPIIJRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> �!/ ���l'0 CITY/ZIP <br /> CROSS STREET I C APN Dc-)7 q'00S'51 ` m <br /> PARCEL SIZE <br /> �,[//� IV <br /> OWNER NAME j � n 1 �)��G�n PHONE 9 <br /> OWNER ADDRESS LI I I r v- G I ,Di- 2 C4 CITY/STATE/ZIP 4(4wPQ <br /> CONTRACTOR M'�'ti l "1 `Gt /''/,C' PHONE <br /> CONTRACTOR ADDRESS `f /7L�YJ // CITY/STATE/ZIP <br /> LICENSE ❑ -42 ❑IJC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: C' NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> C REPLACEMENT 11 OUT-OF-SERVICE SEPTIC SYSTEM )( DESTRUCTION 1 1G1V1)< <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: "��In NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG U✓1cy lC L CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> -100 , 90 ft <br /> DISTANCE TO NEAREST: WELL oft FOUNDATION ft PROPERTY LINE <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ..jj D <br /> LEACH LINES Li LEACHING CHAMBERS #OF LINES -.L LENGTH OF LINES T ft <br /> �-y�/ <br /> DISTANCE TO NEAREST WELL �� ft FOUNDATION-ft PROPERTY LINE �V 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 <br /> 3 j ft DEPTH c�s ft <br /> DISTANCETONEAREST WELL GC/,,d� ft FOUNDATION /y 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 ��6leL/a`►. DATE <br /> T <br /> � N <br /> F TA <br /> T <br /> �J DEPARTMENT USE ONLY q <br /> Application Accepted By /�—� Date 5 / Vu Area % Employee ID# DK <br /> Final Inspection ByDate ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of Ft: Pit/Sump Soil Character: S O� 5 F-1 h�AM <br /> COMMENTS O 9 M3 00d lines �( lae ,, �,`p :ir <br /> PE SC Received eck# Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash Remitted Service Request# <br /> 4a►o IIs -70 1 S10 ! , l� <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />