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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 INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP <br /> r� <br /> CROSS STREET �.�yj'»,� a, w�� APN 0860a a03 PARCEL SIZE ),Q. <br /> OWNER NAME�d /. -1119/ � � rY,U CI PHONE <br /> 44'1 <br /> OWNER ADDRESS I C// ,'-sb YI I GF ` CITY/STATE/ZIP S7 X kio�m <br /> CONTRACTOR G dL4�d�( �jfyl/►/CZ�Q�� <� (�X,�i PHONE !9 :sz —')4W <br /> 7' <br /> CONTRACTOR ADDRESS �z b izza k)AA) CITY/STATE/ZIP <br /> LICENSE ❑GC-42 11t1C-36 OTHER NUMBER �J(� J EXPIRATION DATE_/. :2 <br /> e <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# l <br /> TYPE OF WORK: Ll NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> 0 REPLACEMENT D OUT-OF-SERVICE SEPTIC SYSTEM ! DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: :Z= 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 �t� Y�Y7 #OF LINES�_ LENGTH OF LINES Q ft <br /> DISTANCE TO NEAREST WELL 'Z ft FOUNDATION T 42 ft PROPERTY LINE <4- ft <br /> O 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 It FOUNDATION ft PROPERTY LINE ft <br /> ® SUMPS WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> Q DISPOSAL PONDS WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER z WIDTH y ft DEPTH ZS / _ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE S /st- _ 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 /> MIN/ 48 H URADVANCEN / E REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLEDATE <br /> PAY ENr <br /> VED <br /> 2020 <br /> 145�:11c, WN <br /> O Q N_ OUNTy <br /> H E TAL <br /> TMENT <br /> DEPARTMENT US ONLY /� <br /> Application Accepted By Z L Date5/4,470,7o Area '1 v/ Employee ID# DA ' 7 <br /> Final Inspection By Date )( SPECIAL PERMIT-Approved by ✓Tw <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS �uye of line.. On I'�'jA NelCharin5 y4eM7over I fcc+ <br /> evwa Fie % <br /> �f >•6 - <br /> PE SC Received hec Amount Date P rmit/ Invoice# Permit ID# <br /> Code INFO B ash Remitted Service Request# <br /> 4x10 iii X300 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />