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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)4663470 <br /> NON-REFUNDABLE PERMIT CALL <br /> 209 953-7697 FOR INSPECTIONS EXPIR <br /> ES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 2/U y ,� ( /L��,�.%4/' VLC /ZIP /� .'� ✓!(-/". 7 ' <br /> CROSS STREET APN o ZD k PARCEL SIZE <br /> //�� - - <br /> OWNER NAME /[' / /ted.`' �S u PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTORC L �,�/d S..P•J �' PHONE <br /> CONTRACTOR ADDRESS L!d C/ 1}`��/"� ��'� C� CRY/STATEIZIP <br /> LICENSE O',C-42 O._,C-36 OTHER / NUMBER 1 EXPIRATION DATE <br /> WATER TABLE DEPTH: V R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAtR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM M' DESTRUCTION <br /> INSTALLATION WILL SERVE: P RESIDENCE D COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: J / NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br /> O SEPTIC TANK TYPE/MFG L `J—L CAPACITY / J gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE To NEAREST: WELL /GVH R FOUNDATION —S R PROPERTY LINE 5—C) R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ACHING CHAMBERS —StiaAr,O #OF LINES LENGTH OF LINES <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> ,XFILTERBED WIDTH /7 R LENGTHv R DEPTH 1I-2 tI R <br /> DISTANCE TO NEAREST WELL c)Q R FOUNDATION 7 J- ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH it LENGTH fl DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION fl PROPERTY LINE R <br /> ❑ SUMPS WIDTH R LENGTH fl DEPTH fl <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE fl <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION fl PROPERTY LINE fl <br /> ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. �I <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMU448 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209)953-7697 <br /> SIGNED TITLE %1,✓h",4�-f'��' DATE <br /> 1 <br /> q-C OZ <br /> NTY <br /> L <br /> NT <br /> DEPARTMENT USE ON Y q <br /> Application Accepted By Date Area ( Employee ID# <br /> Final Inspection By 'I Date ' / ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to D pt f 3 t Pit/Sum Soil Character: <br /> COMMENTS G � ,— LW X <br /> PE SC Received Check#/ Amount t Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Re uesI# <br /> TS 5W -rr�� 1 3531011 <br /> u ) <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 /� <br />