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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 209 953-7697 FOR INSPECTIONSS� EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 3Sn I �- 40CITY/ZIP /P*G:S/ K4- U <br /> CROSS STREET 46I,ACA APN_ 0�ra 7 PARCEL SIZE <br /> OWNER NAME ,, �. <br /> ��l P'�'S _ PHONE <br /> OWNER ADDRESS 16 f1 t�1.tr i � CITY/STATE/ZIP jc��T <br /> CONTRACTOR Vh 4SL` 5y f - PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP j�aAM,,,4 <br /> LICENSE ❑FIC-42 ❑IIC-36 OTHER_ NUMBER_(1EXPIRATION DATE lrcl 7 <br /> .4 <br /> WATER TABLE DEPTH: _ t ! ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# 7 LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION I 1 PAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> 11 REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM c! DESTRUCTION <br /> INSTALLATION WILL SERVE: jPrRESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: If NUMBER OF BEDROOMS: r NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG �ti-L. CAPACITY j lV (�C2 gal #OF COMPARTMENTSt7'__ <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL_L��� ft FOUNDATION 3S ft PROPERTY LINE lia ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT 0 SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> X� LEACH LINES 11 LEACHING CHAMBERS #OF LINES�I" LENGTH OF LINES /J15 ft <br /> DISTANCE TO NEAREST WELL An I ft FOUNDATION_Uh ft PROPERTY LINE 43f 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 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 tjOiffl ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE C >A NC-f16 i- DATE r1 t' 19 <br /> 00 <br /> F y '� <br /> D E P AR T M E N TV S N L Y <br /> Application Accepted B _ Date_ Area _ s/G/�i/ Employee IDvkk <br /> Final Inspection By _ _ DateT ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of At: _ Pit/Sump Soil Character: <br /> COMMENTSTtE L-[ (nl <br /> k - ter _may60 <br /> PE SC Received Chec Amount Permit/ <br /> Code INFO B ash Remitte Date Service Request# Invoice# Permit ID# <br /> l Ot'01.101 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />