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4 <br /> 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 ADDRESSA5" 1-AAA CITY/ZIP �� <br /> CROSS STREET �� 1 Mi (/U /C!/ APN O I !3 1 4 PARCEL SIZE p <br /> 0 <br /> ////� z <br /> OWNER(NAME G (/�l)/I���1 PHONE � <br /> n <br /> OWNER ADDRESS JI�d, CITY/STATE/ZIP �j Q <br /> CONTRACTOR '`rL &41,� ))�!/L� � PHONE <br /> CONTRACTOR ADDRESSf'yL/4/ 'vC.•�C/ CIN/STATE/ZIP <br /> LICENSE ❑ C-42 ❑'_-.C-36 OTHER 4 NUMBER `, EXPIRATION DATE <br /> WATER TABLE DEPTH: I V ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # F BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATIONDZ--REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-0F-SERVICE SEPTIC SYSTEM 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 /> W-LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES �L' �" ft <br /> DISTANCE TO NEAREST WELL �G�(� ft FOUNDATION 4 ft PROPERTY LINE -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 WIDTHl `�� / ft <br /> ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION PROPERTY LINE 41- 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 48 HOLUMR AD ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE <br /> lilt <br /> T � <br /> > DEPARTMENTU EONLY <br /> Application Accepted y �/` l L Date .?/ Area rf Employee ID# ER <br /> Final Inspection By DateV. �i ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 F : Pit/Sump Soil Character: <br /> COMMENTS few]. E,YlstinK hnPs }a fc-ro lbl - T,pr <br /> PE SC Received ChecRV Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Remitted I Service Request# <br /> �13i`1 115 �O �S �S3ofl ��Is- <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />