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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 CPERMIT CALL 209 953-7697 FOR INSPECTIONS ) EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 5 / �D /(i �1JY��N CITY/ZIP /,-�1 <br /> CROSS STREET lLe./llen�.� Lvr�..�, APN O J PARCEL SIZE <br /> jy o <br /> OWNER NAME �/s'C "i /�L)A,)CL AyJ PHONE �, Ll �G / <br /> U. <br /> OWNER ADDRESS/ / J �/� (7J CITY/STATE/ZIP LZ'cf <br /> CONTRACTOR C-�yJ/}�j1 //�G/ ��� PHONE S-;,Z-7 <br /> CONTRACTOR ADDRESS / Z C- CITY/STATE/ZIP <br /> LICENSE ❑JLC-42 ❑ C-36 OTHER NUMBER / ,/d/.EXPIRATION DATE 61%IZ/ <br /> WATER TABLE DEPTH:_-70 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION K REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: -f NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG r_�/�, 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 /> 91-LEACH LINES I- LEACHING CHAMBERS #OF LINES LENGTH OF LINES qJ' ft <br /> DISTANCE TO NEAREST WELL J ft FOUNDATION �S ft PROPERTY LINE S 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 JO ft DEPTH <br /> DISTANCE TO NEAREST WELL_)5& ;O�' ft FOUNDATION ft PROPERTY LINE <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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR IN PE //T--I N - PLEASE ALL 2 953-769 <br /> SIGNED =- TITLE �i9/72 x DATE y Z <br /> V <br /> F <br /> Q4 11A, <br /> ,Q <br /> DEPARTMENT USE ONLY (q4 D Fi <br /> Application Accepted �` Ll� Date / � � Area / Employee ID# <br /> Final Inspection By ` Date 6�!0%21 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of Ft: Pit/Sump Soil Character: <br /> COMMENTS :5:L54em E. yjsb'y-t; Imes 4 <br /> PE Sc Received Check Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash RemittedService Request# <br /> 13 its � 3 s,� i ,5,' 1e 93 2.7 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />