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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 ©Q V elv P.:0 CITY/ZIP st <br /> CROSS STREET L /"//"/ I J / APN M_4,—�o �JyPARCCCEL SIZE 9��{ c <br /> OWNER NAME • GT PHONE r �( / L ��J rn <br /> A <br /> OWNER ADDRESS C7 ITY/STATE/ZIP <br /> CONTRACTOR < 7 <br /> HN <br /> CONTRACTOR ADDRESS ^ / CITY/STATE/ZIP <br /> LICENSE ❑P.0-42 111—JC-36 OTHER <br /> n! �✓/� U <br /> � <br /> ~ NUMBER �/C�Oy`� EXPIRATION DATE �O _ "'D " ' O <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION I REPAIR/ADDITION 11 ENGINEER DESIGNED/ALTERNATIVE - {. <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION fly PT fG / CJ <br /> INSTALLATION WILL SERVE: I I RESIDENCE I I COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG 1117 (10 <br /> 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 ft FOUNDATION ft PROPERTY LINE AYMEN <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTHt <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> L3SUMPS WIDTH ft LENGTH ft DEPTH SM JOAQUIN CPhn aftOU <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE HEAI Tu ncn.N L <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ttWIT <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT I VE 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 OUNTY. <br /> INIM VANCE NOTICE REQUIRED FOR INSPECTP EASE CALL 209 9 3-769 <br /> SIGNED TITLE DATE <br /> lo <br /> Full I <br /> DEPARTMENT JOSE CINLY <br /> Application Accepted Date Area Employee ID# ,4W4, <br /> Final Inspection By Date C ElSPE AL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/S mp Soil Character: <br /> COMMENTS G +njy ;jQk.1Vy-�J-)tial Q <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO B sh emitted Date Service Request# Invoice# Permit ID# <br /> 42-01 � �(/ ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />