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v <br />C ' <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />-1691 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE <br />CITY/ZIP / <br />/ <br />AP 11 J 1 ✓ - ?— L PARCEL SIZE !/ <br />PHONE <br />OWNER ADDRESS / / CITY/STATE/ZIP G �/ <br />CONTRACTOR n(1 11 hVJJy(li� 71;44yel, PHONE S % _ 24!! � <br />CONTRACTOR ADDRESS 3 / Z% �°L/RCGI "' I D CITY/STATE/ZIP <br />LICENSE ❑C-42 ❑I7C-36 OTHER NUMBER D EXPIRATION DATE ( _ �S <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />[IPERC TEST # BUILDING PERMIT #?JILAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION I-) REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE <br />U REPLACEMENT U OUT -OF -SERVICE SEPTIC SYSTEM I DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: I .L ! NUMBER OF BEDROOMS: 1 � ) NUMBER OF EMPLOYEES: <br />SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY c;bO O gal # OF COMPARTMENTS C <br />L CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL �C1' 1 ft FOUNDATION S " ft PROPERTY LINE /S_c s ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />.1 <br />LEACH LINE } /Cl LEACHING CHAMBERS # of LINES \ a3 / LENGTH OF LINES /D ft <br />\ <br />I DISTANCE TO NEAREST WELL �D 4-' ft FOUNDATION �� � ft PROPERTY LINE 140 Offt <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(3) WIDTH a r ft LENGTH , lG % ft DEPTH la ft <br />\\ DISTANCE TO NEAREST WELL C900-11-- ft FOUNDATION �� ft PROPERTY LINE .,5-� ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />?,r5 --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 ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />TITLE ��`�Z/' DATE a5 �a�oZ <br />SIGNED ! <br />E Q /N <br />y MN <br />N <br />EPARTMENT USE QN.LY <br />Area ( Employee ID#Final <br />Application Accepte11�3 Date�70 <br />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 />INFO <br />Received <br />B <br />Chec <br />s <br />Amount <br />Remitted42A <br />Date <br />Perm <br />R <br />Service Req # <br />Invoice # <br />Permit ID# <br />I <br />2 B <br />.25.22 <br />S <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />T <br />