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t <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 FRO DATE ISSUED <br /> // ' <br /> JOB ADDRESS CITY/ZIP <br /> /J�AN T�^A Z' <br /> CROSS STREET APN io PARCEL SIZE <br /> r ° <br /> OWNER NAME C J <br /> N PHONE <br /> OWNERADDRESS D ,19 ITY/STATE/ IP p�/ I/ yn V t <br /> CONTRACTOR 4� �AJ�'�� PHONE —2 J~"/" / �7 <br /> CONTRACTOR ADDRESS 4111"Lf !�C/�/(�+�'�- ��� ^� �^ CITY/STATE/ZIP �'�J 47 I JI 3,J"O-- <br /> LICENSE ❑11C-42 ❑1 IC-36 OTHER__ _-___ __ NUMBER /� J y�� EXPIRATION DATE <br /> i <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # PUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: LI NEW INSTALLATION REPAIR/ADDITION ' ENGINEER DESIGNED/ALTERNATIVE <br /> q REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM A DESTRUCTION L <br /> INSTALLATION WILL SERVE: P RESIDENCE 11 COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: / NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> Iff SEPTIC TANK TYPE/MFGCAPACITY / V gal #OF COMPARTMENTS —%- <br /> 13 GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL Z-41!P10 - ft FOUNDATION S t ft PROPERTY LINE ft <br /> ® LIFT STATION SIZE_ TYPE OF PUMP t7 PKG T):PLANT Ell SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES LEACHING CHAMBERS #OF LINES li �LNGTH OF LINES _ r u ft <br /> DISTANCE TO NEAREST WELI_ y T ft FOUNDATION- I L)A- I't PROPERTY LINE �7r� 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 /> 1 DISTANCE TO NE RESTOlt <br /> ELL ft FOUNDATION ft PROPERTY LI E ft <br /> SUMPS CZ/ WIDTH LENGTH 01-6- 1*2i ft DEPTH ! ft <br /> DISTANCE TO NEAREST WELLI*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 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 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE� DATE <br /> pit <br /> veh <br /> cc <br /> tTyR E N <br /> N <br /> EPARTMENT SE OINLY <br /> Application Accep:U�= <br /> Date _ Area Employee ID <br /> Final Inspection B _ Date ( ❑ SPECIAL ERMIT-Approved by <br /> Character of Soil to Depth of Ft: Pit/Sump Soil Character: <br /> COMMENTS tiyatw4gd && <br /> PAO <br /> I/ ( "�,L S _ ism- _CPAhA&Li i��/ �a^ iat kZA- <br /> PE Sc Received Che Amount Permit/ <br /> Code INFO B ash emitted Date S v' a nest# Invoice# Permit ID# <br /> o or <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />