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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 I I, I CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS �� Sa S tin ,,CITY/ZIP <br />�/�/j <br />CROSS STREET _/ Y I ;iU ii In i V1 kw -'e- APN Q09 4 (0 060�- PARCEL SIZE <br />OWNER NAME �.t ('�Q� S }- '�1 �C� �j t�PHONE <br />OWNER ADDRESS 177,!�6�=b Unr\.S iyz4 - WD —CITY/STATE/ZIP <br />/% /) / SL�((/� �✓�'►4 <br />CONTRACTOR f��-�C.\� �f�`l�l�j >1-L/�r' PHONE <br />CONTRACTOR ADDRESS "PO 6 (S C.P� %! CITY/STATE/ZIP 44 <br />LICENSE 111IC-42 ❑0C-36 OTHER NUMBER l!d EXPIRATION DATE DD < �- <br />WATER TABLE DEPTH: So- L10 <br />ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # G> F7 LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION LI REPAIR/ADDITION !J ENGINEER DESIGNED /ALTERNATIVE <br />CI REPLACEMENT J OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: ESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />SEPTIC TANK TYPE/MFG 04 CAPACITY gal # OF COMPARTMENTS_ <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL 1"5a* ft FOUNDATION L61 ft PROPERTY LINE 1n I ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />MX'EACH LINES ❑ LEACHING CHAMBERS # OF LINES LENGTH OF LINES lrr ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION �7 I ft PROPERTY LINE ��) I ft <br />❑ FILTER BED WIDTH ft LENGTH 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 48 HOUR Aj2VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED TITLE � Cs.� ,�11` acs C DATE gZ <br />DEPARTMEN7us UIVLr <br />Application Accepted By � Z -Z-- Date - 'AreaS' Ja S Employee ID# -� <br />Final Inspection By a o (..(101 f alF v � Date ,2 I / (Z� ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: PPit/SumpSoil Character: <br />COMMENTS tJeO SFR 1 k)I/ 1"PSl P)76e Tl' PY <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />42-01 <br />4/14/18 <br />r <br />Sc <br />INFO <br />Received ec <br />B ash <br />Amount <br />Remitted <br />Date <br />I I <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />PE <br />Code <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />42-01 <br />4/14/18 <br />r <br />