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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^ ,�n ,CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �d f/ J O //7'�/� / CITY/ZIP <br /> n1 e � <br /> CROSS STREET YUSe�'�` T' /�Ile--APN �7 / ���-Z �PAARCEL SIZE 42-0 <br /> OWNER NAME � 41 <br /> t!'01'� SLkkl� 1�L G/aPHONE 40 413- `I-2.37 <br /> OWNER ADDRESS Z _zw, CITY/STATEIZIP <br /> CONTRACTOR �� PHONE S r f 53 J <br /> CONTRACTOR ADDRESS f%y`7 / '� L/,r,(-W ^1 ^y CITY/STATE/ZIP /-)�?yj <br /> LICENSE ❑❑C-42 00C-36 OTHER NUMBER rye J EXPIRATION DATE !I /30 17 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: O NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> L <br /> INSTALLATION WILL SERVE: D RESIDENCE 4 COMMERCIAL El 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 ft FOUNDATION ft PROPERTY LINE ft <br /> 46 FILTER BED WIDTH ft LENGTH f0 ft DEPTH 3 0 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION /OJ ft PROPERTY LINE S- ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> C� 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 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�TtJ -/i9G�� DATE <br /> kAD <br /> PA r <br /> O Q <br /> Ni. CIA <br /> M N <br /> R Jy <br /> DEPARTMENT USEfONLY C <br /> Application Accepted B Date Area Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to D th of 3 Ft: Pit/ ump Soil Chara ter: <br /> COMMENTS j�er LI. c�-t'�!tM� No W s <�' <br /> d d, 'e of -L.n _ <br /> l11 .Vd 0 r �4 fa I(Aae _ ° <br /> PE SC Received hec Amount Permit/ <br /> Code INFO B Cash Remitted Date Service Request# Invoice# Permit ID# <br /> t� <br /> � 6n l z Sys,2vh .1s a;K ;v+ S as a, a 14 <br /> 42-01 -1 t C f!� M k4,5'f- ( ktC­� "'fO t��1 r ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />