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y ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> S.-"N 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 �7 �G�>y �/�Yy7/Zt�Jnu�r 1/N�� CITY/ZIP <br /> n -� <br /> CROSS STREET � e—'e � APN 01-' 31 O 2—` PARCEL SIZE Y <br /> 0 <br /> Iz <br /> OWNER NAME NL.J 3?liiiNL PHONE <br /> OWNER ADDRESS J / / CITY/STATE/ZIP <br /> CONTRACTOR C,G�/7�n /�1'J/TT/7C PHONE 7W,.-5DZ;? <br /> CONTRACTOR ADDRESS �/ 6 r7L/ etil y!�� //� CITY/STATE/ZIP 5J71Pi <br /> LICENSE Eb�,C-42 ❑ C-36 OTHER NUMBER /5 yG y EXPIRATION DATE J%/Z% <br /> 1 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# - LAND USE APPLICATION# <br /> TYPE OF WORK: 7L NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM G DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: j NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG it�!f z- CAPACITY Zyy gal #OF COMPARTMENTS Z <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> _ s <br /> DISTANCE TO NEAREST: WELL GCS ft FOUNDATION ft PROPERTY LINE 50 <br /> _ ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 5- LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES JAS ft <br /> DISTANCE TO NEAREST WELL ZU� ft FOUNDATION ft PROPERTY LINE S U 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 `',33 ft DEPTH 3S ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION d ft PROPERTY LINE SCJ r 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 ADVANCE NOTICE RE IRED FOR INSPE TI N - PLEASE CALL 209) 953-7697 <br /> �> /- <br /> SIGNED TITLE ef,'.'1/7=''�_ -�- DATE ��� <br /> i <br /> VP T1 <br /> U 144 <br /> CI:)UlM <br /> N IR N E T <br /> H E kL7 H <br /> 7DEPARTMENT USE ONLY <br /> Application Accepted By ' ' Date ` c, Area 1 Employee ID# <br /> Final Inspection By i Date Z ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS ' hac. Z''c� <br /> L <br /> —qg i <br /> PE Sc Received RKe-ck#W Amount kte Permit/ Invoice# Permit ID# <br /> Code INFO B Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/16 <br />