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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 209 953-769.7 FOR INSPECTIONST �/ EXPIRES 1 YEAR FROM D-zAT'E]ISSUED <br /> r <br /> JOB ADDRESS 6 .6 CITY/ZIP /A 1 N 4,t c j <br /> - m <br /> CROSS STREET APN I'7 � D �V PARCEL SIZE <br /> d <br /> T <br /> I C�/' O <br /> OWNER NAME (J hc( ✓ c IM t�-` PHONES (l'y( e) t> <br /> OWNER ADDRESS O �``0,y_ n 1 CITY/STATE/ZIP <br /> CONTRACTOR VV �f PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 111-C-42 1111C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ P!ERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I I NEW INSTALLATION REPAIR/ADDITION I ENGINEER DESIGNED/ALTERN/1TIVE <br /> 1 REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION VV IIL }t 0 k <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY 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 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 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 ft <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 1 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 /> WjAWVM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONSnn-PLEASE CALL 209 953-7697 7 <br /> SIGNED TITLE_),A)2IL— DATE Q j �� 2° Zo <br /> MrIll <br /> PA O QLUN <br /> HE D M Nry <br /> T <br /> DEPARTMENT USE ONLY <br /> Application Accepted By r Z--Z_ Date 20dO Area Employee ID# 1A <br /> Final Inspection By Date 20 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 F+t::) Pump Soil Character: <br /> COMMENTS' M �f1�l�L t/1 (.l Ayi lyw(i pll + A S IZJosj l0zo <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> IS't� Ot <br /> F "---T-- — - - - <br /> 42-01J,,;�M(ab'2_D <br /> ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />