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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 ff //EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS �(� /�w' V CITYIZIP SIL'kkl ' rI <br /> CROSS STREET APN D'� �" PARCEL SIZE O 1 y <br /> 0 <br /> a <br /> OWNER NAME �IV c PHONE yard- 0703 <br /> ,,�� <br /> OWNER ADDRESS rry'-"C_ CITY/STATE/ZIP 5✓t�[Xhw+ <br /> CONTRACTOR /�Gs�/T4I+1�L G /� id/�= PHONE <br /> CONTRACTOR ADDRESS }7 y� J(/yi2JCEw ��� /�i�' CITY/STATE/ZIP <br /> LICENSE ❑t fi:42 LlC-36 <br /> /'OTHER NUMBER 7 S/U`�� EXPIRATION DATE )Ch-'yzy <br /> 1 V <br /> WATER TABLE DEPTH: - ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I I NEW INSTALLATION REPAIR/ADDITION I I ENGINEER DESIGNED/ALTERNATIVE <br /> I I REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM I I DESTRUCTION <br /> INSTALLATION WILL SERVE: i4.RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: y NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG /�Ci�1vc3 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 1 LEACHING CHAMBERS #OF LINES�_ LENGTH OF LINES '/U ft <br /> DISTANCE TO NEAREST WELL %OL ft FOUNDATION :0 ft PROPERTY LINE ZU 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 1_2 ft LENGTH /C' ft DEPTH 7Z ft <br /> DISTANCE TO NEAREST WELL 100 ft FOUNDATION SG ft PROPERTY LINE /(U ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <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 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 <br /> SIGNED --� TITLE /4cDATE Z11-1, 7O <br /> TAfc <br /> J <br /> C <br /> D <br /> DEPARTMENT USE.ONLY <br /> Application Accepted By 1A Date Area Employee ID# <br /> Final Inspection By Date ZOW ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth 3ff.: Pit/Sump Soil Character: <br /> COMMENTS All "� L � S . y'' r d �; l�f, acs kilt' �✓� o <br /> ni <br /> PE SC Received heck# Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B s Remitted Servi a Request# <br /> 2 GCS <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />