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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 CITY/ZIP St-0 <br /> CROSS STREET WOL S}' <br /> n Y� <br /> AP1N_ I f� �V�J PARCEL SIZE l 5 73 220 <br /> OWNERNAME GTn\5AfQSfGIt� PHONE 2��I 7-75-g39I <br /> ,p I <br /> OWNER ADDRESS 5Z6 S iJGIX'l 'i'ay5 czc CITY/STATE/ZIP S 1�C V1 Ci 1 �S2)a <br /> CONTRACTOR O U3 Mz-'r PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑1IC-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: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION CI ENGINEER DESIGNED/ALTERNATIVE <br /> IJ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM Q DESTRUCTION _ <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 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 It <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT U SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES 1=1 LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH It LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH RT <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH q ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN Aa�__ ft <br /> El DISPOSALPONDS WIDTH ft LENGTH ft DEPTH EMI! QUIN ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINA r' i j M_7Z- ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH -- ENT ft <br /> DISTANCE TO NEAREST WELL It 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 11 q <br /> SIGNED TITLE D 0 Y`eX DATE <br /> A IL <br /> t <br /> t DEPARTMENT SE ONLY �+ <br /> Application Accepted By _ Date Area J �mployee ID# <br /> Final Inspection By Date / ❑ SPE AL PERMIT-Approved by <br /> Character of Soil to Depth f 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS +_ S 440ffi _40'�;-Lr <br /> vwy- w � vow. ,Q5� ►��L� a <br /> PE SC Received Ch Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Bash Remitted Service Request# <br /> �-( v s' a S 0$1 <br /> 42-01 /v V '/ day ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 T� lf� <br />