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i <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 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS !� CITYIZIP <br /> �i <br /> n9 � <br /> CROSS STREET�Vlj4L.,V <br /> / APN O -O• O'D3PARCEL SIZE <br /> OWNERNAM ( �0�! V PHONE <br /> OWNER ADDRESS 7 V.5_0 � CITY/STATEIZIP ( - <br /> CONTRACTOR�/Ci L C PHONE !0% 01/ /197 V <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE LI C-42 ❑ C-36 OTHER NUMBER V./� EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: y RESIDENCE i COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: Z .l' NUMBER OF EMPLOYEES: n <br /> - SEPTIC TANK TYPE/MFG �G L CAPACITY /2 bb 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 TYPEOFPUMP ❑ PKGTXPLANT ❑ SAND OIL SEPARATOR(ENCLOSED <br /> �SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES 20/'//>!J& ft <br /> DISTANCE TO NEAREST WELL y d Zak ft FOUNDATION /Q)3 ft PROPERTY LINED ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It <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 WIDTH ` ft LENrGTnH'_�0 ft DEPTH� J ft <br /> DISTANCE TO NEAREST WELL�;ft FOUNDATION /O� ft PROPERTY LINE �T ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft `DVS <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It 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. v <br /> MM&UM 48 HUM ADW6NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 9 53-7699 7 _ Q <br /> SIGNED 01 TITLE �F L� DATE OZ-,1t7—Z_5 <br /> 0 <br /> 4_0 <br /> ^0, <br /> � W <br /> }}�0� <br /> `V <br /> _0 <br /> i Q <br /> EPARTMENT IJSE,6 N L Y YIN Yn�ENT <br /> Application Accepted B Date Area Employee ID# <br /> Final Inspection By Date SPECIAL PERMIT-Approved by EWED <br /> Character of Soil to Depth of 3 Ft: Pit/bump Soil Character: <br /> COMMENTS asp. — FER �� 2025 <br /> JOAQUIN COUNTY <br /> PE Sc Received hec Date Invoice#Amount Permit/ ur•� �I�EP NTAL <br /> ■ I'f <br /> ode INFO B ash ervice Request# TMENT <br /> 7 65 i 2l(�2( vs a <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4114/18 <br />