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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 INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS t0 /LN CITY/ZIP n <br /> CROSS STREET APN 2 O PARCEL SIZE <br /> OWNER NAME C/�/+CU� o / PHONEK/0"T SO <br /> OWNER ADDRESS a ` CITY/STATE/ZIP { <br /> CONTRACTOR ae/�sR �rl-L It �wQ/' PHONE .S //�J —� Ljer�? �� -_ <br /> CONTRACTOR ADDRESS lell"2 ����✓y GW v CITY/STATE/ZIP �J� 444 FS-?J-j— <br /> LICENSE ❑I.0-42 ❑f iC-36 OTHER _ NUMBER{ /f� EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: IJ NEW INSTALLATION F REPAIR/ADDITION I I ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION "`zT060M-1 <br /> INSTALLATION WILL SERVE: AJ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: Y NUMBER OF EMPLOYEES: <br /> / <br /> ® SEPTIC TANK TYPE/MFG ` or-J a CAPACITY 1600 gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG __ CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ��J• ft FOUNDATION ' ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP_ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES I LEACHING CHAMBERS #OF LINES f LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL Z-0 ft FOUNDATION ZcZ)• 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 /> G MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> (J SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> C 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 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE <br /> DATE <br /> VAN­ <br /> OA <br /> N <br /> DEPARTMENT SE ONLY <br /> Application Accepted y Date_ Area Employee ID# <br /> Final Inspection By Date Z ElSPECI L ERMIT-Approved by <br /> Character of Soil to D pth of 3 Ft: Pit/Sump Soil Character: _ <br /> C MMENTS -p��M- <br /> - AA ---- <br /> PE SC Receivedhec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B _ ash Remitte rjervice Rpquest# <br /> 147—Wo C ;��_i 3 .act 31 6K0A10-1w -- <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />