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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 INSPECTIONSL ExPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I�� u /SGI G'C� nn CITY/ZIP LnC���'^ �j`Z71� U <br /> CROSS STREET %�/1/ 1 APN V O3PARCEL SIZE i 3 C C <br /> OWNER NAME __1(r Gi e- i�c( i U D l L' PHONE U <br /> OWNER ADDRESS 7 7 //.) ��L� �i�• CITY/STATE/ZIP )T C' L l z C' v <br /> CONTRACTOR /I� / !i,a)N C r~ PHONE <br /> i <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 11. C-42 [1 IC-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 REPAIRIADDITION I I ENGINEER DESIGNED/,ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM / DESTRUCTION k-01ll� <br /> INSTALLATION WILL SERVE: E RESIDENCE ❑ COMMERCIAL C OTHER <br /> NUMBER OF LIVING UNITS: 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 /> ❑ 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 ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 953-7697 <br /> SIGNED , I I ` C,, TITLE DATE 9-6 <br /> JU114 0 <br /> R N <br /> PRM N <br /> JJ � DEPARTMENT USE ONLY <br /> Application Accepted y �L� Date r O Area y Employee ID# DA <br /> Final Inspection Bye Date �2 2 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: f <br /> COMMENTS t�r�+5e C ?W�. jl urv� (V-,V sj e dtl- ;1iSVal - 5eD fl(- 4-An(� I isly _ <br /> PE SC Received Che / Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By ash Remitted ervice Request# <br /> �d a 1 VO-Fd <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />