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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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jou ADDRESS 5(o4(0 UUCNt }i^i"w"' I Z- CrrY21P 1/04" W <br /> CROSS STREET N• �lEa C�� ti. Twp APN OSS 116-0zi PARCELSIZE 13.35 <br /> OWNER NAME d4- WrfA.N1 W+�l `CI PHONE <br /> OWNER ADDRESS CITY/STATEIZIP <br /> CONTRACTOR T.r1'C V% lGn , 4—, . 'I., PHONE167-37Y„e <br /> CONTRACTOR ADDRESS 9D2 CITY/STATE/ZIP Lad' CA i rZ`,,0 <br /> J <br /> LICENSE ❑I-C-42 11IIC36 OTHER NUMBER [1L4n0`1 ,EXPIRATIONDATE 5 31 a`i <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> B PERC TEST # 3 BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: L NEW INSTALLATION C REPAWADDITION _ ENGINEER DESIGNED/ALTERNATIVE <br /> 1 REPLACEMENT r OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> O SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> O GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> O LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT Q SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> O LEACH LINES F LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTYLINE It <br /> O FILTERBED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE ft <br /> (3 MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> O SUMPS WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTYLINE ft <br /> O DISPOSAL PONDS WIDTH It LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE It <br /> LI SEEPAGE PITS NUMBER WIDTH It 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 HOURADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 3-7697 <br /> SIGNED Z TITLE �9c�Yk GcJlc� S� DATE 9 2) T-3 <br /> V' 1I L <br /> x x <br /> A I c u <br /> DEPARTMENT.USE ONLY <br /> Application Accepted By/11�^� Date -t-3, Area q'II Employee ID# � <br /> Final Inspection By T Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS-fo r Pi ry ,rpt (�u P L`l o y r aln f I Sinn u jZ6L1- <br /> PE SC Rsee vgd Check#1 Amount Date Permit/ Invoice# Permit lD# <br /> Code INFO f /, Cash Remitte Service Re uest# <br /> 4a z Sia "=�i 3 <br /> 42-01 ONS RE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4114/18 <br />