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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 <br /> 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Lis- Q h CITY/ZIP fi�� t r—" ' <br /> CROSS STREET Corr e r APN d b q 330 Oa PARCEL SIZE <br /> OWNER NAME Frcj N k ('o{1zG1/F S PHONE <br /> OWNERADDRESS " ICG117C40 PGY O;'? CITY/STATE/ZIP <br /> v <br /> CONTRACTOR IS�� 8 CC(CLt-n-c— �-QY• PHONE 1--I SC' - � �� •� <br /> CONTRACTOR ADDRESS VA- 17,'r-d CITY/STATE/ZIP <br /> LICENSE C-42 LJ C-36 OTHER NUMBER l BEXPIRATION DATE <br /> WATER TABLE DEPTH: — _IV ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: i NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE I I COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:3 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 /> 131> LEACH LINES LEACHING CHAMBERS #OF LINES _ LENGTH OF LINES r� / ft <br /> DISTANCE TO NEAREST WELL 180I ft FOUNDATION LII ft PROPERTY LINE r� ( 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 f1 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 /> MINIMUM 48 HOUR A VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE Co/ld.[�<t�-0� DATE �2 <br /> 'vT <br /> it <br /> FD <br /> OZj <br /> E /N N <br /> LN "10 <br /> � � <br /> NT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By 1�z­ Date cp a Area ( Employee ID#� <br /> Final Inspection By Date 1 62 ?.l SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft:r=(-t126 GZA t'� Pit/Sump Soil Character: <br /> COMMENTS FC�i 11'r�, sys4ewl• �e;rz;w <br /> PE Sc Received Check Amount Pale <br /> Permit/ Invoice# Permit ID# <br /> Code INFO B Remitted Service Request# <br /> 1A3 » iIS �� <br /> " e 2 s v <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />