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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(209953-7697 FOR INSPECTIONSEXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1 a�D U 1 r VI ") .A^CITY/ZIP p►`C4 f+f <br /> - aa60y 3a � <br /> CROSS STREET \� APN PARCEL SIZE p <br /> n v <br /> OWNER NAMEyVI(°SA Y� � „ 'e'Ir PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR Ur I IH�S'/� PHONE <br /> CONTRACTOR ADDRESS /7�x_���� CITY/STATE/ZIP <br /> LICENSE ❑iCC-42 ❑GIC-36OTHER �� <br /> NUMBEr� EXPIRATION DATE <br /> WATER TABLE DEPTH: do ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: J NEW INSTALLATION REPAIR/ADDITION 11 ENGINEER DESIGNED/ALTERNATIVE <br /> L- REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM iI 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 CHAMBERS #OF LINES}�� LENGTH OF LINES C310 ft <br /> DISTANCE TO NEAREST WELL Ind ft FOUNDATION 3-01' ft PROPERTY LINE .7 S 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 /> 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 H ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 95Y-76 <br /> SIGNED TITLE DATE <br /> N <br /> DEPARTMENT U E ONLY <br /> Application Accepted By ��� Date d/ Area S `7 C Employee ID#_�� <br /> Final Inspection By k. Date 2 2 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pi Sump Soil Character: <br /> COMMENTS 5 ✓� `�� T I >7 11hP " (��u:e i GAS %Y� <br /> Elozd <br /> I , <br /> fr�� 4e el e It -fe - 1PUc� 11�Fs V/ 'O S vJ;YWll <br /> sE, acks P..�?- u.� or6S <br /> PE SC Receiveeck#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> ya i� 11 3� 2Y2 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />