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s <br /> 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 EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS X12 U`�f� // CITY/ZIP N �i <br /> CROSS STREET / �/i I Yi APN LI 0 I PARCEL SIZE <br /> � v <br /> OWNER NAME Keewpr ��Y1 L oe TkHONE <br /> x <br /> (� 'P (m„ <br /> OWNER ADDRESS Op / � Cm oki IeW� CITY/STATE/ZIP �!f Wel, ncle H <br /> CONTRACTOR F L i <°'�>"' PHON S 7 f / J,1�� <br /> CONTRACTOR ADDRESS `/d y • N"< < CITY/STATE/ZIP �� ""r y <br /> LICENSE ❑CIC-42 ❑OC-36 OTHER NUMBER -J V 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 / I' REPAIR/ADDITION CI ENGINEER DESIGNED/ALTERNATIVE <br /> 1 REPLACEMENT I FG+�� k 1 PCU/ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: M' RESIDENCE ❑ COMMERCIAL Ff r I ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: C� r D 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 �-1 LEACHING CHAMBERS .� '0��� r #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ® FILTER BED WIDTH � ft LENGTH z ft DEPTH ft <br /> DISTANCE TO NEAREST WELL SU ft FOUNDATION ft PROPERTY LINE S 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 /> 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE <� - -A DATE <br /> H TH DEPARTIAE111T <br /> f DEPARTMENT USE ONLY G� <br /> Application AcceptedB L—�LLQ Date 1 6 ) Area 3 / Employee ID# <br /> Final Inspection By J4��� Date f I `� I2 G SPECIAL PERMIT-Approved by <br /> _ (-zn Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> h I <br /> �4c F',eIC� �c„ 114. Lxls�'!nti sYSf Pn^ n� e X dsf/>7ti 1 fir. <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO ash Remitted Service Request# <br /> Lid 10 pis O0 I-q 21 'SIP,DO "'� I� <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />