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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 p CALL209 953-7697 FOR INSPECTIONS C E <br /> ,(XPIRES 1 YEAR FROM DATE ISSUED <br /> H <br /> JOB ADDRESS HOS `a G w Qy"( CITY/ZIP_ ____ �7 UL 1 U^ Q,5 2 07 <br /> H <br /> ve 077--330 -0q 30 <br /> CROSS STREET U APN PARCEL SIZE fl a <br /> OWNER NAME " C PHONE / CMCI 7 -"711r 612 m <br /> OWNER ADDRESS I /nV�� �')'IVtIM�G� CITY/STATE/ZIP <br /> A _ <br /> CONTRACTOR n (-3 lI PHONE 1�'��L� <br /> CONTRACTOR ADDRESS �I u W�� y e_ CITY/STATE/ZIP ��i�iY� -on l 1 (ivJ <br /> LICENSE 11JC-42 ❑LC-36 OTHER NUMBERS-7`l 35_7 EXPIRATION DATE Sb Z. <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED TERNATIVE <br /> -. REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM xl DESTRUCTION Y1 , <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ r72EASE 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 I LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE `74Z-2-I <br /> i <br /> A J E T L <br /> DEPARTMENT US ONLY <br /> Application Accepted By L Date 71d� p� Area I� Employee ID# DA <br /> Final Inspection By — Date 7—$1 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS C,,qrec 'I Se PY <br /> ,sj�,�� <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO 13y Cash Remitted atP Service Request# Invoice# Permit ID# <br /> y0 opsL <br /> 4 v / l ONSITE WASTEW T -RTMNT SYSTEM PERMIT <br /> 4/141/14/18 <br />