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a 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 o EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS L/ZAL P"(,2 CITY/ZIP Cr�yl/L�yJ1 S <br /> �JA <br /> CROSS STREET mr� ry /��• APN va Z oa 0 D3 PARCEL SIZE <br /> OWNER NAME PHONE�7/Z'6U/k- v� <br /> OWNER ADDRESS �. AJX 7'LL &Lsl� CITY/STATE/ZIP d emeA e3 Baa� N <br /> CONTRACTORy/ G �f/�� PHONEC�/'SC�Z7 <br /> CONTRACTOR ADDRESS -3/^7t/5.., ✓ grw y�lXf 9,G CITY/STATE/ZIP <br /> LICENSE ❑NC42 ECC-36 OTHER- NUMBER EXPIRATION DATE ClJ/�G/z_l <br /> WATER TABLE DEPTH: J a / ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION / 014, REPAIR/ADDITION /e6: G'ck a I 1 ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT _ 2557Wk OUT-OF-SERVICE SEPTIC SYSTEM A DESTRUCTION fC4VJ k <br /> INSTALLATION WILL SERVE: t4-RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: Z/'"_3 NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG CAPACITY 01�7_1e_!> gal #OF COMPARTMENTS Z <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE SO Y- ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES F LEACHING CHAMBERS #OF LINES LENGTH OF LINES ��� ft <br /> DISTANCE TO NEAREST WELL /00 ft FOUNDATION ft PROPERTY LINE C) 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 eft} FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER WIDTH ft ft DEPTHS/ ft <br /> DISTANCE TO NEAREST WELL_j SCS ' ft FOUNDATION /UL 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 209 953-76 7 <br /> SIGNED TITLE �la� DATE li�e3 C, <br /> Oq <br /> NO <br /> P <br /> vii La <br /> DEPARTMENT USE ONLY <br /> Application Accepted B Date 073 -1'D.t D Area Employee ID# DA <br /> Final Inspection By Date ` 11SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS Fci ilutP %i V541'eyt1• 7"e, <br /> PE Sc Received Ch Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash Remitted Service Re uest# <br /> I <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />