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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 vJU w� I /h Cc t'�" CITY/ZIP_ C c-/ )S / �� <br /> CROSS STREET -6'!c &% APN PARCEL SIZE C <br /> OWNER NAME k- J /) I/C PHONE <br /> OWNER ADDRESS ///0 S T1 �Q CITY/STATE/ZIP <br /> CONTRACTOR /1/Ia I—< 1l'v�� L �` �f" �' PHONE S 7 y JIf <br /> f T <br /> CONTRACTOR ADDRESS C y ' y` �✓ J' CITY/STATE/ZIP !nw/ /9 1 J <br /> LICENSE -1 C-42 ❑ C-36 OTHER / NUMBER Z�S 3 EXPIRATION DATE /� c'/ <br /> WATER TABLE DEPTH: I'ef5 f hij,1 l 10 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION I. / ❑ REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE <br /> A'- REPLACEMENT Tic ' ` S i IP ❑ OUT-OF-SERVICE SEPTIC SYSTEM -r DESTRUCTION 4"t 1l k <br /> INSTALLATION WILL SERVE: rte' RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: / NUMB/ER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG �! d G �>'lJC-ft`Z CAPACITY /Z 0 L.J gal #OF COMPARTMENTS z, <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE i 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 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> -® FILTER BED WIDTH 11/ ft LENGTH S^r-:� 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 48W. 6UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-7697 <br /> SIGNED / `~ TITLE _r� � /k. DATE <br /> �T <br /> C� <br /> q <br /> lrj l <br /> M <br /> M <br /> 9 DEPARTMEN USE ONLY <br /> Application Accepted By /`��� Date Area S Employee ID# _ <br /> Final Inspection By Date I Z ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE Sc Received Che Amount a Permit/ Invoice# Permit ID# <br /> Code INFO By Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />