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e � <br /> a <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 /> f" y <br /> JOB ADDRESS �'d I �C oY' Ag s CITY/ZIa1 'C <br /> ! cc. <br /> CROSS STREET __- APNy I T� PARCEL SIZE _ p <br /> OWNER NAME C1, PHONE ��6`j` <br /> w <br /> OWNER ADDRESS CITY/STATE/ZIP r/ <br /> CONTRACTOR_ ( � ��{_(�_l _ _ �P f• PHONE <br /> CONTRACTOR ADDRESS �c� ��IC S _ — CITY/STATE/ZIP t/V1'4'f-'---*4 j�/r� <br /> LICENSE 11IAC-42 ❑CIC-36 OTHER_ NUMBER(aF5S,R EXPIRATIONDATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# l <br /> TYPE OF WORK: l) NEW INSTALLATIONREPAIR/ADDITION I i ENGINEER DESIGNED/ALTERNATIVE <br /> I REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM CI DESTRUCTION <br /> INSTALLATION WILL SERVE: 4,1 -PE S I DENC E <br /> RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: J NUMBER OF BEDROOMS:-3 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 /> EACH LINES I i LEACHING CHAMBERS #OF LINES J-- LENGTH OF LINEo ft <br /> DISTANCE TO NEARESTWEL FOUNDATION /�t ft PROPERTY LINE ft— <br /> 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 VNE ft <br /> SUMPS WIDTH a ft LENGTH to I ft DEPTH a ft <br /> DISTANCE TO NEAREST WELL PROPERTY LINE <br /> t&&). 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 48 H U ADVANCE NOTICE REQUIRED FOR INSPECTIONS-- PLEASE CALL 209 953-7697 <br /> SIGNED TITLErr DATE <br /> yl <br /> Jillr <br /> F N <br /> N <br /> TT <br /> DEPARTMENT USE ONLY <br /> Application Accepted ELy Date Area Employee ID#_) <br /> Final Inspection By Date ❑ SP CIAL PER IT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMME TS U u <br /> PE SC Received Che Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Bxn Cash Remitted Service Request# <br /> v <br /> s 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4114/18 <br />