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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 /> JOBADDRESS �! L �� �''� G y�CITY/ZIP <br /> -� <br /> f <br /> CROSS STREET ?"Per APN �C) /0 -f6/ l7 PARCEL SIZE � <br /> v <br /> 0 <br /> ^ z <br /> OWNER NAME AI"V Z4 /A.--i J PHONE y <br /> OWNER ADDRESS p tG CITY/STATE/ZIP <br /> CONTRACTOR s&e e4�,((r C rc `. ,,-, � PHONE _� 7 � — <br /> O�Ie <br /> CONTRACTOR ADDRESS /`� r ^�'L� V CITY/STATE/ZIP <br /> r <br /> LICENSE ❑CiC-42 11FIC-36 OTHER NUMBER-?I II `?VJj EXPIRATION DATE / 43z <br /> WATER TABLE DEPTH: 16S AG1 m �� ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION G REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> P REPLACEMENT funk 3 (,,J 1- OUT-OF-SERVICE SEPTIC SYSTEM if DESTRUCTION T�✓I� <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL Z ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: I h d r UMBER 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 S— ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES E LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> m FILTER BED WIDTH ft LENGTH ��� ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE _S 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 ������c�U� DATE 3-- 5—? c I <br /> 1-17 <br /> j <br /> J q <br /> R IL <br /> RT wp <br /> EPARTMENT USE ONLY <br /> Application Accepted B r Date Area Q G9 Employee ID# & <br /> Final Inspection By. Date�jl 14f2,1 ❑ SPECIAL PERMIT-Approved by <br /> V 00 <br /> Character of Soil to Depth of 3 Ft: Pit/ imp Soil Character: <br /> COMMENTS V ' , <br /> J v ct . v <br /> V� os� <br /> PE SC Received heck#/ Amount P mit/ <br /> Code INFO B as Remitted Date Service Request# Invoice# Permit ID# <br /> y d» I IS- 1211 G12 DOJND2- <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />