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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-RIEFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROMDATEDATE ISSUED <br /> JOB ADDRESSlJ� V CITY/ZIP Ca I Z' <br /> !J . T <br /> CROSS STREET �� C V APN 1517/ - //V - 07 PARCEL SIZE �. 12 <br /> �y c <br /> OWNER NAME ,J Iavil A4 va <br /> + PHO&jt /^r (/"U -8 f <br /> OWNER ADDRESS C 4s. �a ( LSA✓ ` CITY/STATE/ZIP V1(/ Mr I <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑CIC-42 ❑LjC-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: NEW INSTALLATION LI REPAIR/ADDITION ENGINEER DESIGNED IALTERNATI E <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM jK DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> T 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 /> ❑ LEACH LINES -; LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 /> MINIMUM 48 HOUR 42VANgE <br /> 2NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 953-76977 <br /> SIGNED TITLE ✓7G/ DATE —23 �U <br /> SAN J A UI C UNn <br /> NIR NMENTAL <br /> --F[EkL1Ht kW <br /> EPARTMENT USE OJYLY pp <br /> Application Accepted By Date Area l -1 Employee ID#_� <br /> Final Inspection By Date Z M�0.17 0 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: V IF Pit/Sump Soil Character: <br /> COMMENTS �' U' Lj O' <br /> Y- <br /> 'g:f2r� ! 4 o <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO By Cash Remitted at Service Request# Invoice# Permit ID# <br /> O ( `J Z `7 $ <br /> 42-01 '�" y <br /> "— SITE STEW ER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />