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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1865 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS p EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /,d 'ZS F FJD V✓U 0 0 /t 0 CITY/ZIP TR'fry r_"e) v� <br /> 9 S C/�/� BoeorlZSJ p <br /> CROSS STREET APN_�Q/O//7/ PARCELSIZE 4,000 56)•x, d <br /> C <br /> OWNERNAME PII-CKy COF/J PHONE(�L-J)6107- 3909 <br /> OWNERADDRES$ /��Z,S IeC I�4�00nr� CITY/STATE/ZIP TPI CYC r/1 <br /> CONTRACTOR Q Zan," r7-'2 PHONE <br /> CONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE ❑OC-42 ❑DC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# 'O LAND USE APPLICATION# <br /> TYPE OF WORK: x NEW INSTALLATION 0 R AIR/ADDITION ❑ ENGINEER DESIGNED IALTERN IVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> ty NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: Z NUMBER OF EMPLOYEES: <br /> p. SEPTIC TANK TYPE/MFG CAPACITY I( Zoo gal #OFCOMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES 0 LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH It LENGTH _ ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <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 It <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 HOUR ADV NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE t il/P ytL✓/v DATE J�z <br /> 0001 1 <br /> n <br /> IT <br /> D <br /> t 1I SAN, <br /> VIj <br /> QjjM C DU TY <br /> PA NT <br /> EPARTMENT US ONLY <br /> Application Accepted By Date Area Employee ID#A---q ,s./��'�("/( <br /> � <br /> Final Inspection By Data ❑ S"ItPE IAL RMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS , <br /> PE SC Received hec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash Re to Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />