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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 -2)09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS l ���/� J 7��r-�f" °�- /�/J - CITY/ZIP <br /> rr <br /> CROSS STREET r1C� I'1 /� APN / /«J PARCEL aSIZE <br /> OWNER NAME PHONE <br /> OWNER ADDRESS /L 1 I rte` / n(' CITY/STATE/ZIP J���t'����/• �'/ r G� �� <br /> CONTRACTOR '��� / _l<<v� PHONE ���i'/f)j7 �7� <br /> CONTRACTOR ADDRESS /U y ��'�i✓ c -/ CITY/STATE/ZIP <br /> LICENSE [ LIC-42 11IJC-36 OTHER NUMBER J '/J3 EXPIRATION DATE <br /> WATER TABLE DEPTH: I3J ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# C D ISLAND USE APPLICATION# <br /> TYPE OF WORK: OF NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> .. REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: r RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: S� NUMBER OF EMPLOYEES: <br /> "❑ SEPTIC TANK TYPE/MFGC -������ CAPACITY fZsr" gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE 6�' ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES I' LEACHING CHAMBERS r G) S �, #OF LINES_� LENGTH OF LINES Fi ft <br /> DISTANCE TO NEAREST WELL_`^`� ft FOUNDATION ft PROPERTY LINE s' - 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 /> EY SEEPAGE PITS NUMBER WIDTH ft DEPTH 2 ft <br /> DISTANCE TO NEAREST WELL /Sy ft FOUNDATION ft PROPERTY LINE ft <br /> 1 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 4&HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS1-PLEASE CALL (209)953-7697 <br /> SIGNED TITLEDATE // J <br /> 129P =1 k1crk <br /> SAN O Q IN UN <br /> EM haff__ <br /> DEPARTMENT USE ONLY <br /> Application Accepted By GL—// Date 11 dUa Area G Employee ID# D/t <br /> Final Inspection By Date C SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PiUSump Soil Character: <br /> COMMENTS A)f ,J SFR . /"Vp OedS: Inti 1110 IS-3 FFN?� �r()24S j2F-' <br /> PE SC Received tuacww Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Reauest# <br /> �Id 3 117 /Wx <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />