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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 FROM DATE ISSUED <br /> JOB ADDRESS p /T ✓fr CITY/ZIP Zf <br /> ..t <br /> CROSS STREET <br /> S< � L A�PN3 <br /> PARCEL SIZE <br /> OWNER NAME /GPHONE <br /> /// CITY/STATE/ZIPOWNERADDRESS /17 � <br /> Z11.7 ��E(his 9 0 0 1 <br /> CONTRACTOR /`%�� —I�jy�N�"s/ PHONE ,Z o 9 Z yy 9a9G <br /> CONTRACTOR ADDRESS U� � U ��J�� CITYISTATE/ZIP <br /> LICENSE 1117IC-42 []PC-36 OTHER ��� NUMBER EXPIRATION DATE <br /> i <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: 0 NEW INSTALLATION 0 REPAIR/ADDITION Li ENGINEER DESIGNED/ALTERNATIVE <br /> III REPLACEMENT 0 OUT-OF-SERVICE SEPTIC SYSTEM 0 DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> UMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> F-KSEPTIC TANK TYPE/MFG — CAPACITY gal #OF COMPARTMENTS <br /> EI GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> EY LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES 0 LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 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 /> E# MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE_ ft <br /> EI SUMPS WIDTH _ ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> El DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL _ ft FOUNDATION ft PROPERTY LINE ft <br /> E➢ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> t 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 /> MINIMU HO ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-76 7 <br /> SIGNED TITLE %�� 6GTOfL DATE -710b <br /> G <br /> l <br /> o <br /> F T <br /> EPARTMENT OSE ONLY _ <br /> Application Accepted By Date Area Employee ID# 9 <br /> Final Inspection By Date ❑ SP CIAL PER IT-Approved by <br /> Character of Soil to De i ';TfF PituMmp Soil Character: <br /> COMMENTS OI<I <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO B Cas Remitted Date Service Re nest# Invoice# Permit ID# <br /> 5 Z 0-1 .2o Iq R00 <br /> 42-01 �/����� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 (/I ? 666/ll f� <br />