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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 4683420 <br />NON-REFUNDABLE FEERMIT t '{� UALL (LU -4) -447J-/0-4/ FOR INSPECTIONS �r-XPIRES l YEAR FROM DATE ISSUE <br />JOB ADDRESS - 1-�L 7- VJ - E ES W CfrY%LIP -T1�n "tCSi 97,304 <br />CROSS STREET LE -weiei -b APN 2-49 - 230-O f PARCEL S^I�ZE�yGt•��'`�^�• <br />OWNER NAME DO UG To CL F- S PHONE S-10' <br />OWNER ADDRESS Sit CITY/STATE/ZIP <br />CONTRACTOR C-l\IE DPriG- PHONE 3(fl�j-o`3�S- <br />CONTRACTOR ADDRESS L40-1 w ' U �'� S"r' CrrY/STATE/ZIP (-OTS (77 <br />LICENSE ❑BC -42 110C-36 OTHER e�� NUMBER Z1S 1 EXPIRATION DATE q -3O -ZZ <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />1 PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: 0 NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br />❑ REPLACEMENT I OUT -OF -SERVICE SEPTIC SYSTEM 0 DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPEIMFG CAPACITY gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />E LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />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 <br />REGULATIONS OF SAN JOAQUIN <br />COUNTY. <br />MINIMUM <br />OUR AD NCE NOTICE REQUIRED <br />FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED <br />TITLE 10j2 -0j • <br />Y1 &j2-- DATE <br />10P <br />IV7)- <br />DEPARTMENT USE ONLY r <br />Application Accepted By �L- Date�p/J1:2 Area 5 <br />« Employee ID#A� <br />i <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 Received Check <br />INFO B ash <br />Amount <br />Remitted <br />Date Permit/Perm Invoice# PermitlD# <br />Service Re uest# <br />-FOS <br />42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/16 <br />