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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 / 7 EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS )/ CITY/ZIP J fO/i/�d/z '7 y�l/�2- L/' <br /> /� p ,rte z ]� <br /> CROSS STREET ,(/nom,/LSA_ '7 x !I / APN 0 J 3JDv PARCEL SIZE O� /` p <br /> OWNER NAME �/L l� i/L� S� ) yecc`/^ '�l/ T O9 J 04111 <br /> PHONE <br /> OWNER ADDRESS 1C1)��F CITY/STATE/ZIP <br /> CONTRACTOR A e-L VA S zf2j 4)'A PHONE v// r4 2: G� ) <br /> CONTRACTOR ADDRESS 11022;-4 /I�/t'�(/ i^-6// CITY/STATE/ZIP J a,e <br /> LICENSE 0_.0-42 LIIIC-36 OTHER �/'1 NUMBER l/�/��y�J EXPIRATION DATE��C� <br /> WATER TABLE DEPTH: / C-'� ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION I I ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: L4 <br /> 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 /> LEACH LINES LEACHING CHAMBERS #OF LINES_ LENGTH OF LINES T/� ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> L3FILTER 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 N WIDTH J ft DEPTH ft <br /> DISTANCE TO NEAREST WELL_ ft FOUNDATION 16 ft PROPERTY LINE ',L 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 /> MINIMJM 48 HQUa ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 9533-7697/ <br /> SIGNED TITLE eC/ DATE <br /> T <br /> ­Evv 11 <br /> - a � <br /> DEPARTMENT USE ONLY T <br /> Application Accepted 80 Date C /E• .��� Area G C� Employee ID# DA <br /> Final Inspection By Dat2JZ' ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to D th of 3 Ft: PiUSump Soil Character: <br /> COMMENTS � ��517J�1}'1 - s '$ �F'� S��.l ;)1c C1�r/11. �,�' �J} ir F 40 <br /> of <br /> �/ �,nf6S�i1 !S� to i^Fi tigvyS >JCP t�yH pD��C� p,7 IyP1 n CLser <br /> PE SC Received / Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />