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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 FRRO�M^DATE ISSUED <br /> JOB ADDRESS /�Y -A A R//J /P CITY/ZIP <br /> CROSS STREET ! '�y/�)61YI4P6�� <br /> APN �,� 7 (] J PARCEL SIZE p <br /> v <br /> OWNER NAME <br /> �J AJ D PHONE <br /> OWNER ADDRESS C: ` CITY/STATE/ZIP /�I�J� ��7 A SJ <br /> 3 y <br /> CONTRACTOR r/' ISA I'� =:f/247 C PHONE s— <br /> CONTRACTOR ADDRESS /Y�� C r ��►�ll l�/` / CITY/STATE/ZIP <br /> LICENSE 1110-42 ❑LIC-36 OTHER / NUMBER /�L�J EXPIRATION DATE u ?��Z / <br /> WATER TABLE DEPTH: ICx�S +hc W )0 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ii 1 NEW INSTALLATION/, REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> io REPLACEMENT Lem /- kdf—I 1 OUT-0F-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: kg RESIDENCE ❑ COMMERCIAL ❑ 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 /> C LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> t <br /> DISTANCE TO NEAREST WELL ft FOUNDATION < ft PROPERTY LINE c? 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 /> MINIMUMA8 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE f•V �K' �' DATE -L <br /> U/ <br /> n, eAt <br /> T <br /> T <br /> DEPARTMENT US-E ONLY <br /> Application Accepted By Zi Date 7,113 Area G G Employee ID#� <br /> Final Inspection By Date —7 f"-f,1-7Xn j ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of-3 Ft: Pit/Sump Soil Character: <br /> COMMENTS Cy5jem • 6t, ciben6�.j7e, <br /> S <br /> PE SC Received QSLQrke Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash Remitted i I Service Re uest# <br /> Lqd to lls- 0D .& 2 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />