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4 <br /> 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 OR INSPECTION EXPIRES 1 Y FROM DATE ISSUED <br /> JOB ADDRESS C,,IT++Y/ZIP <br /> CROSS STREET 1� APP-GJ I —U1*0- 17 PARCEL SIZE <br /> OWNERNAME PHON <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR V PHONEM!R - <br /> CONTRACTOR ADDRESS ��CIT��YIS TATE/Zly <br /> ozLICENSE C42 C-36 OTHER � NUMBER _f;;QATION DATE?�3 .... <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> D PE RC TEST # BUILDING PERMIT# LAND USE APPLICA ON# <br /> TYPE OF WORK: NEW INSTALLATION REPAIRIADDITION NGDJEER DES NED ALTER T <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTIO <br /> INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASETRAP TYPE/MFG CAPACITY gel #OFCOMPARTMENTS <br /> DISTANCE TO NEAREST: WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTYLINE ft <br /> [HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE W ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MIN/Mukr411mu A O ICE RE UIRED FOR INSPECTIONS-PLEASE CALL 209 953-76 7 <br /> SIGNED TITLE 'Cno DATE <br /> I <br /> Pg r <br /> D A R TMEALL SE NL T <br /> Application Accepted Date Area �4 Im <br /> ployee ID#It CF�V�D <br /> Final Inspection By _-�� _ Date Z SPECI PERMR-Approved by <br /> Character of Soil th of t: Pit/Su Soil Cha��rl1cter: <br /> COMMENTS C '34 ?026 <br /> 4fEAL- <br /> OU�pCOv <br /> PE SC Received ec Amount Permit/ "�[ E <br /> Code INFO B Cash miffed Date Service Re uest# Invoice# Permit ID# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />