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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 c CALL(209)953-7697 FOR INSPECTIONS / ExPIRES/1^YEAR FROM DATE ISSUED <br /> JOB ADDRESS Z�j �lYil® CITY/ZIP L�/L�GU/✓ LZ� fj <br /> CROSS STREET ls� (/ /�'"�� APN C9f 3100 y PARCEL SIZE <br /> C <br /> C <br /> OWNERNAME //, T1IPY PHONE <br /> OWNER ADDRESS lo7y� 1V Inlll' I���l CITY/STATE/ZIP Li�(.�P►'7 9s�a73�� <br /> (�G�jl+n{ /�( fJ C PHONE ...),�/ ,��P y _ J"P7 <br /> CONTRACTOR �/ <br /> CONTRACTOR ADDRESS ( � ' `'�T` r� i CITY/STATE/ZIP �"r / elf— <br /> LICENSE ❑X-42 ❑I C-36 OTHER NUMBER (5-�d7 f EXPIRATION DATE <br /> WATER TABLE DEPTH: L/5- <br /> IJ ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# RP-3OD)s.5' LAND USE APPLICATION# <br /> TYPE OF WORK: I NEW INSTALLATION I_i REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> `r NUIMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> JI,J SEPTIC TANK TYPE/MFG CAPACITY //�O gal #OF COMPARTMENTS a <br /> [[[❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE rP�> ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES / LEACHING CHAMBERS I7 P''f l #OF LINES LENGTH OF LINES -�S ft <br /> / ` DISTANCE TO NEAREST WELL �b' s ft FOUNDATION �S 00ft 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 /> SEEPAGE PITS NUMBER WIDTH 'l ft DEPTH Lft <br /> DISTANCE TO NEAREST WELL 000 ft FOUNDATION �0 ft PROPERTY LINE v�OC) 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 <br /> NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9/553-7697 <br /> SIGNED % �L� �Y !✓ TITLE �H/ DATE <br /> r <br /> N <br /> R <br /> DEPARTMENT USE ONLY <br /> Application Accepted B� � Date 7 Ooi O Area Employee ID# D�1 <br /> Final Inspection By DateC7/Z3,/?.,2c- ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS tj 1,J SFP- �iHr <br /> PE SC Received Check Amount Permit/ <br /> Code INFO B ash Remitted Date Service Re uest# Invoice# Permit ID# <br /> qd 13 117 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />