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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 c CALLA 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS (-( ��� S4-f`I `Ye-� 1`� CITY/ZIP SGS b l� Ili <br /> APN <br /> CROSS STREET CCS•"r/�J /'/ '[ " / I PARCEL SIZE p� <br /> / /Zle ITAS <br /> OWNER NAME � C---�C�Z . PHONE 71 <br /> OWNER ADDRESS / [- CITY/STATE/ZIP <br /> CONTRACTOR 5L-6 I 'W,J nPHONE H / G/ <br /> �� <br /> CONTRACTOR ADDRESS lb 6c, (,cJ cc CITY/STATE/ZIP •�,�/t0✓4,.' 9. 1C✓I` `� (� <br /> LICENSE IJ C-42 � C-36 OTHER NUMBER OS EXPIRATION DATE at-") � <br /> WATER TABLE DEPTH: U ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT#,, LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> � REPLACEMENT 6 OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE l COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: ( NUMBER OF BEDROOMS: -3 / \ NUMBER OF EMPLOYEES: <br /> B---'S'EPTIC TANK TYPE/MFG �(f L- CAPACITY gal #OF COMPARTMENT <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL I ft FOUNDATION *4 S 1 ft PROPERTY LINE 16/ ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES lJ LEACHING CHAMBERS #OF LINES 4�- LENGTH OF LINES C6/ ft <br /> DISTANCE TO NEAREST WELL (061 ft FOUNDATION IO 1 ft PROPERTY LINE 1 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 /ftt FOUNDATION ft PROPERTY LINE ft <br /> [3,"SUMPS WIDTH Z ft LENGTH b( I ft DEPTH I61 ft <br /> DISTANCE TO NEAREST WELL ( 4g6l ft FOUNDATION ra I ft PROPERTY LINE S I ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> O SEEPAGE PITS NUMBER (/ WIDTH ft DEPTH ZS ft <br /> DISTANCE TO NEAREST WELL �(� + ft FOUNDATION I 01-r ft PROPERTY LINE S 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 ADV NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 20 953-7697 <br /> SIGNED TITLE �7�ct�a e.�c�(' DATES ;6 oZ I <br /> U <br /> IQ r �v GOLN <br /> EPARTMENTUS ONLY <br /> Application Accepted By Date AZO rm or <br /> Area Employee ID# <br /> Final Inspection By Date /zU l'm-zlf ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE Sc Received Check# Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Remitted Service Re uest# <br /> (� CF, <br /> IL <br /> ��2QQ5-sl ILA <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />