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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 <br />CALL 209 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUE <br />JOB ADDRESS <br />Permit ID# <br />�l <br />•/�/� <br />WELL Ldli ft <br />FOUNDATION Ian ft PROPERTY LINE O I ft <br />%, <br />'� <br />/� ��CITY/ZIP <br />C � U�(VV APN (/ 3:0 <br />PARCEL SIZE �o <br />CROSS STREET <br />C-4- <br />E/ <br />DISTANCE TO NEAREST <br />OWNER NAME <br />C� <br />r <br />► ` <br />PHONE <br />WIDTH <br />2 a a <br />f <br />I L V -e— �`� <br />�O + <br />OWNER ADDRESS _! <br />DISTANCE TO NEAREST <br />CITY/STATE/Z1IP' <br />ft <br />CONTRACTORMtY�a <br />❑ SUMPS <br />a 6—e— ` PHONE <br />ft LENGTH <br />CONTRACTOR ADDRESS <br />ft DEPTH ft <br />AOylL �Q CITY/STATE/ZIP %�O�A <br />��t/� �eu�. 41.5 3 J 0 <br />LICENSE ❑C!C-42 <br />❑11C-36 OTHER <br />NUMBER 4 EXPIRATION DATE <br />�10 <br />E <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT I# LAND USE APPLICATION # <br />TYPE OF WORK: 11 NEW INSTALLATION REPAIR/ADDITION ❑ NGINEER DESIGNED /ALNATIVE <br />I I REPLACEMENT _I OUT -OF -SERVICE SEPTIC SYSTEM STRUCTION C2 <br />INSTALLATION WILL SERVE: ESIDENCE El COMMERCIAL <br />OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: a NUMBER OF EMPLOYEES: �1 <br />SEPTIC TANK TYPE/MFG P iAl CAPACITY gal # OF COMPARTMENTS eL <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION K, ft PROPERTY LINE <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />Q2/"LEACH LINES <br />H LEACHING CHAMBERS <br />Check#/ Amount <br />Casli Remitted <br /># OF LINES ` LENGTH OF LINES r ft <br />Permit ID# <br />DISTANCE TO NEAREST <br />WELL Ldli ft <br />FOUNDATION Ian ft PROPERTY LINE O I ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION ft PROPERTY LINE ft <br />SEEPAGE PITS <br />NUMBER :)L- <br />WIDTH '36(1 <br />ft DEPTH 1S ft <br />DISTANCE TO NEAREST <br />WELL I g a i- <br />ft <br />FOUNDATION ft PROPERTY LINE_ -j 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 />SIGNED <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to Dept <br />COMMENTS f /d <br />3 Ft: <br />-ke-4--i-r <br />DEPARTMENT USE ONLY <br />Date U f 3 / 7 /1 Area (� <br />Date tq�C)Z, II3Z2,\ ❑ SPECIAL <br />Pit/Sump Soil Character: -4-- <br />DATE 24c-% <br />P ti <br />Employee ID# \� <br />ERMIT - Approved by <br />MAN <br />PE SC <br />Code INFO <br />Received <br />B <br />Check#/ Amount <br />Casli Remitted <br />Date Permit/ Invoice # <br />Seryice Req uest # <br />Permit ID# <br />$ 2� <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />