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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 PERMITT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �iT4�1 Wee: �jJz CITY/ZIP / L- f 19-k <br /> CROSS STREET CAAPN A — 3(� I PARCEL SIZE <br /> OWNER NAME h0 PHONE <br /> v; <br /> OWNER ADDRESS S,>�„�� CITY/STATE/ZIP <br /> CONTRACTOR ryry� (+) 1 O!"S PHONE <br /> CONTRACTOR ADDRESS I I �/ I TH CITY/STATE/ZIP J�/(/ l(/ CA <br /> LICENSE L1--C-42 ❑1C-36 OTHER NUMBER # EXPIRATION DATE f,� 8 hD�D <br /> WATER TABLE DEPTH: 7>3 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAI ADDITIO I ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT I OUT-OF- ERVICE SEPTIC SYSTEM I I DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF ROOMS: 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 O S ft <br /> DISTANCE TO NEAREST WELL n l r ft FOUNDATION O`d/ 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 It 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 /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT 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 8 ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL 2 �+ )3-7697 <br /> SIGNED TITLE 0INP-1i- 'L DATE /o <br /> 5 LIZ MIENTI <br /> qpNjqkQlpIN C <br /> E T <br /> rd <br /> EPARTMENT LYSEhNLY <br /> Application Accepted B Dats ,g/ Area Employee ID# <br /> Final Inspection By Date Z Lts SPE IAL PERMIT -Approved by <br /> Character of Soil to Depth of 3 Ft. Pit/ ump Soil haracter: <br /> COMMENTS <br /> • <br /> PE SC Received 6'ck#/ Amount ate Permit/ Invoice# Permit ID# <br /> Code INFO Cash mitted Service Re uest# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/16 <br />