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r � <br /> TREATMENT SYSTEM PERMIT <br /> ONSITE WASTEWATER <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 /_ 9 CITY/ZIP JIyJ�� <br /> CROSS STREET /cC=WW 1`'IGIC �� APN�/7-3YO"l�-/ PARCEL SIZE b <br /> d <br /> 7� <br /> OWNER NAME PHONE <br /> �S/t`� _PHONE y <br /> OWNER ADDRESS -7-0s- 4&( 14.,4.- ©CiI.G.- yj CITY/STATE/ZIP <br /> CONTRACTOR S Il��L LI, Cr PHONE <br /> CONTRACTOR ADDRESS _ � �,_/ice yJ �G G�U� CITY/STATE/ZIP <br /> ❑ <br /> LICENSE �.42 ❑ / <br /> L1C-36 OTHER NUMBER _ SfUfS EXPIRATION DATE C J <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# I CIO 11`7 LAND USE APPLICATION# <br /> TYPE OF WORK: �4- NEW INSTALLATION 11 REPAIR/ADDITION U ENGINEER DESIGNED/ALTERNATIVE <br /> I_i REPLACEMENT 1.1 OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL A- OTHER SAI0� - <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTICTANK TYPE/MFG f,L CAPACITY Moo gal #OFCOMPARTMENTS :2 <br /> ❑ <br /> GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENT <br /> DISTANCE TO NEAREST: WELL ZSb�,4- ft FOUNDATION , _ ft PROPERTY LINE _ lva— ft <br /> ❑ LIFT STA7ION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES 11 LEACHING CHAMBERS #OF LINES_� LENGTH OF LINES / r ft <br /> DISTANCE TO NEAREST WELL 'SO/' ft FOUNDATION f0 ft PROPERTY LINE ILoD ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH _ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE _ ft <br /> C WOUNDED 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 /> 1.-j DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> l- SEEPAGE PITS NUMBER .9 WIDTH ft DEPTH '�25, ft <br /> DISTANCE TA NEAREST WELL ft FOUNDATION .149' 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 HOUR ODVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL 209 953-7697 <br /> SIGNED TITLE <br /> VT <br /> Jp <br /> N ip <br /> E <br /> N <br /> DEPARTMENT.USH ONLY <br /> Application Accepted By Date Area 4,, Employee ID#_S <br /> Final Inspection By Date ❑ SP IAL PERMIT-Approved by <br /> Character of Soil to Depth o 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Xheck#W Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />