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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) 953-7597 FOR INSPECTIONS tXPIRES l YEAR FROM UAIL ISSut <br />ff <br />JOB ADDRESS �T) tP -1 q q T • CITY/ZIP G�P O 'I S -?- Z O <br />CROSSSTREET I�+i"W "� 1 1 E' Fj9-0­1�PVC�lf APN OI -1- 0-2-O -0(O PARCEL <br />{SIZE p,(S�. <br />OWNER NAME KC ��� �'��'� PHONE C 30� 4" - qi 340 <br />OWNER ADDRESS 3350 E-- A- P' FPC' ¢D CrTY/STATE21P Cn `� ��20 <br />CONTRACTOR LlVt O,°C"y &e0F V1azNmENIPlL PHONE 3bC7-C13'1 <br />CONTRACTOR ADDRESS 4c) -i VJ - 0 f4,� �g- CRY/STATE/ZIP t"0 -C> t LE U <br />LICENSE ❑I..:C-42 ❑OC -36 OTHER C E `-' NUMBER �' (S I EXPIRATION DATE 44-30 —ZZ <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />PERC TEST #BUILDING <br />PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />NEW INSTALLATION ❑ <br />REPAIR/ADDITION <br />❑ ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT I..i <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />❑ DESTRUCTION <br />INSTALLATION WILL <br />SERVE: ❑ RESIDENCE <br />❑ COMMERCIAL <br />❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />WIDTH <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />Ll LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES <br />ft <br />*ReceivedChec <br />s.� <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ FILTER BED <br />WIDTH <br />It LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />It <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />It <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />It <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 />Application Accepted By Date �) Area I`LL Employee ID#_ <br />Final Inspection By Date ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS <br />PE <br />Code <br />SC <br />INFOash <br />Amount <br />Remitted <br />Permate Invoice # Permit ID# <br />Service Request 4 <br />LIaaG <br />*ReceivedChec <br />s.� <br />is, <br />12 \1 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />