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f • <br /> e <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 jPERMIT f t CALL 209)953-7697 FOR INSPECTIONS ,�E"XPIRES 1AYEAR FROM DATE ISSUED <br /> JOB ADDRESS /l y\�6 6 �Yl T'� !/V 1 CITY/ZIP S�c4<-fq^ /CIT <br /> CROSS STREET {1 Z tied�q� o /A�PN ' r1 .a I GPARCEL U <br /> LLA RCEL SIZE'_`�_�— <br /> OWNER NAME dV +nc- liV�� 1'qn r+..t PHONE 4tp �qf a O ver <br /> OWNER ADDRESS i0o 0,)n)( I L4,4 N CITY/STATE/ZIP <br /> CONTRACTOR M i rr-.�S q '� 5:e r- PHONE <br /> rT <br /> CONTRACTOR ADDRESS ��_-�'��; S _ CITY/STATE/ZIP 1NLcnA.ec* r �� <br /> LICENSE Df-1C-42 C! C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: 1-1 NEW INSTALLATION O REPAIR/ADDITION IJ ENGINEER DESIGNED/ALTERNATIVE <br /> I REPLACEMENT I-I OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: U-5ESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: , 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 /> LEACH LINES C LEACHING CHAMBERS #OF LINES l LENGTH OF LINES y0 i ft <br /> DISTANCE TO NEAREST WELL 18ft ft FOUNDATION S,0` ft PROPERTY LINE �?D� 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 /> SEEPiaGE PITS NUMBER �L_ WIDTH 3c.to <br /> ft DEPTH ggS t ft <br /> DISTANCE TO NEAREST WELL 1ate— ft FOUNDATION Ido 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 ! � I_7 QvRC'! R� DATE � / <br /> 71 <br /> J <br /> V / C <br /> D N <br /> DEPARTMENT USE ONLY <br /> Application Accepted Date Area mployee ID# G�-- <br /> Final Inspection By Date I, ILWN ❑ SPE AL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS l) S <br /> PE SC Received C Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Bash Remitted Service Request# <br /> CoW <br /> 4-1 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/16 <br />