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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-REIFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS�,J EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ` �AL"` -FAW L." /�f CITY/ZIP lillk rsr- f'ft- 7 Z_ <br /> CROSS STREET /N L 2-1:1 APN / ! 7� ��r 1/ PARCEL SIZE �/ =- <br /> OWNER NAME AIIOOW4ti PHONE <br /> OWNER ADDRESS -CITY/STATE/ZIP <br /> CONTRACTOR OCt/NE� �U/LT PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑ C-42 ❑ C-36 OTHER NUMBER EXPIRATION DATE <br /> ( 1 <br /> WATER TABLE DEPTH:ZD V ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT 1, OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: X RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: z—/VPD NUMBER OF BEDROOMS: 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 /> Ir <br /> LVA LEACH LINES LEACHING CHAMBERS #OF LINES I LENGTH OF LINES ft <br /> fl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION— 4- ft PROPERTY LINE ,rjb� t 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 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 /> MNIMU9448 R A NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL 209 953-7697 <br /> SIGNED TITLE / (.�//y6�- DATE <br /> VE 14T <br /> rh <br /> SAN p Q-UINj',01 NIT <br /> I Vit &IT <br /> D ARTMEN TUS ONLY <br /> Application Accepted 13y e Area Employee ID# <br /> Final Inspection By Date ❑ SPEC AL PERMIT-Approved by <br /> Character of Soil to Depth of 3 F . it/Sump Soil Character: <br /> COMMENTS <br /> `C, cl•t GC /<2 S P.N YW 10ZO_a .4C-1 Ion 1A 4 (-. �-i v� 00- , <br /> PE SC Received / Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> I gG � i•a • sRc�gl ��- <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />