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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 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS A17C/ W List t 1�I` CITY/ZIP L <br /> CROSS STREET APN 21 Z 470 - 1/z PARCEL SIZE p <br /> OWNER NAME �, PHONE A <br /> OWNER ADDRESS CITY/STATE/ZIP�f 1 (/' <br /> (� �' <br /> CONTRACTOR yAS Jc:JT`Le �� PHONE /i`��1 ///�V Lr 6-31/ <br /> CONTRACTOR ADDRESS �L1 C ! `I CITY/STATE/ZIP ✓t n 41 <br /> LICENSE W-42 111IC-36 OTHER NUMBER U EXPIRATION DATE ✓� //Z <br /> WATER TABLE DEPTH: 0 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I NEW INSTALLATION rC REPAIR/ADDITION I I ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT _ OUT-OF-SERVICE SEPTIC SYSTEM CI DESTRUCTION <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 /> ❑ 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 CHAMBERS111 #OF LINES LENGTH OF LINES 1190 ft <br /> DISTANCE TO NEAREST WELL L0"�,�jy• ft FOUNDATION ZJ ft PROPERTY LINE FYI 5��t 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 /> MIN UM a HOU VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE nT�'h cn DATE <br /> 22 <br /> J <br /> V/ / <br /> D N <br /> _ T- <br /> EPARTMENT USE O LY <br /> Application Accepted By Date Z- Area Employee ID# <br /> Inspection By t—I. Date 2 - ❑ SPIEL— <br /> FinalL FERMI -Approved by <br /> Character of Soil to De th of/3 Ft: /Pi Sump Soil Character: <br /> COMMENTSg�7�1 C r?,�i1� __ .�_�l.t,Yy ��c /f�..�ti✓ <br /> PE SC Received Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Servicp Request# <br /> o 5— <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />