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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 FERMI CALL 209 953-7697 FOR INSPECTIONS ® EXPIRES 1 YEAR FROM DATE ISSUED <br />4%%/ <br />JOB ADDRESS t / L C �n CITY/ZIP vG a <br />CROSS STREET A APN ��L X" Z Z PARCEL SIZE / <br />d <br />OWNER NAME I C 1TL 1h'/4J PHONE 1 '(F6 <br />OWNER ADDRESS L fl'Sv✓�' V CITY/STATE/ZIP <br />CONTRACTOR 1 C ^ PHONE <br />CONTRACTOR ADDRESS �, !�' i"/►�l 1 ' CITY/STATE/ZIP ���' Ca_ ' 3 y <br />LICENSE 1111C422 ❑0C-36 OTHER / 1 NUMBER yJ� EXPIRATION DATE <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: COOrdlnateS X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: 11NEW INSTALLATION 11REPAIR/ADDITION 11ENGINEER DESIGNED /ALTERNATIVE <br />® REPLACEMENT ElOUT-OF-SERVICE SEPTIC SYSTEM & DESTRUCTION Iy� <br />INSTALLATION WILL SERVE: 'M RESIDENCE ElCOMMERCIAL F1OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />in <br />SEPTIC TANK <br />❑ GREASE TRAP <br />❑ LIFT STATION <br />TYPE/MFG 1 A 4Z � <br />Ce <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL/ <br />SIZE TYPE OF PUMP_ <br />_ CAPACITY / �'�'-' gal #OF COMPARTMENTS � <br />CAPACITY gal # OF COMPARTMENTS <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ PKG TX PLANT L3SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES � LEACHING CHAMBERS S- � � �> #OF LINES/ 2 LENGTH OF LINES y -7Z ft <br />DISTANCE TO NEAREST WELL /U..J ft FOUNDATION L%v e 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 />L3SUMPS 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 Z WIDTH _ ft DEPTH ft <br />DISTANCE TO NEAREST WELL j J ft FOUNDATION jc7fj 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 />COMMENTS® r' <br />Application Accepted <br />Final Inspection By <br />Character of Soil to Depth of 3 Ft:_ <br />DEPARTMENT S ONLY <br />Date � 0 � I Area � Employee ID# �� <br />Date ❑ SPECIAL PERMIT -Approved by <br />Pit/Sump Soil Character: <br />LTJ <br />42-01 <br />4/14/18 <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />