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. a <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 CITY/ZIP D v <br /> CROSS STREET U,V 17 _ APN 0 C) 3 3/ PARCEL SIZE L D <br /> OWNERNAMEwlfluC.I /�,3 ��1&wzLLn� PHONE <br /> L� <br /> OWNER ADDRESSy/7 �� i /�fTca '00 CITY/STATEIZIP C� t�c� / /✓ v <br /> CONTRACTOR �GLr PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 11--C-42 11EJC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: O ft GEOGRAPHICAL INFORMATION: COordhnates X Y <br /> ❑ PERC TEST # BUILDING PERMIT#M, LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION R PAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE I I COMMERCIAL 11 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 ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL /p0 fi 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 /> ❑ 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 /> C SEEPAGE PITS NUMBER WIDTH 4'21r ft DEPTH 2� ft <br /> J DISTANCE TO NEAREST WELL ! f ft FOUNDATION C� 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 /> MI MUM . VB=A2ZM9E NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 953-7697 <br /> SIGNED - TITLE 6L9 4,)4, '_ DATE <br /> I JET <br /> JI <br /> LC Q I <br /> MN <br /> T <br /> DE PIARTMENT 11 SE 0A LY <br /> Application Accepted By Date Area Employee ID# <br /> Final Inspection By ' Date ❑ SPE AL PERMIT-Approved by <br /> Character of Soil to DeIA Ftp Pit/Sump Soil haracter: <br /> COMMENTS <br /> u /l <br /> v w 60(� .6 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitt d Service Request# <br /> l 1 lU �t �� ��� 1,3,H O <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />