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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS AJ• SA-b L M f"iZ N C BR. CrrY/ZIP j+C-A-yK P6 1577-7-0 <br /> N <br /> CROSS STREET Lo CMM Jv-J APN 0 ciz-3(PC-19- PARCEL SIZE 2- <br /> O <br /> OWNER NAME 20a��' DCL ��N� PHONE zd U S-X+o,4 <br /> H <br /> OWNER ADDRESS s✓ ' CrrY/STATErZIP <br /> CONTRACTOR L1Lr UK ' Cf o CA"Y!(Z0 wj r"E N TPt L PHONE 311 Ci ` a3�� <br /> 0 1 �- L_o�� r �si•Eo <br /> CONTRACTOR ADDRESS � CITY/STATE/ZIP ca <br /> / <br /> LICENSE ❑CIC42 [10C-36 OTHER C:oan NUMBER ZI� 4 <br /> 1 EXPIRATION DATE ` —3o-2-L <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> 7$77jRC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDMON ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #CF 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 CJ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 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 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 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.H0UR ADVANCE NOTICE REQUIRED FOR IN PE TI N -PLEASE CALL 209 53-7697 <br /> SIGNED TITLE ' 'K61Z DATE <br /> I i <br /> I <br /> I � <br /> IIII or <br /> ��� <br /> �VZO <br /> I ` <br /> V1, COON <br /> H ENTqL <br /> RTFt�ENT <br /> �--� / DEPARTME TiUS,;31VJy Area I �"/ Employee 1D# DA <br /> Application Accepted By ���� �� D-tT775—a <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received heck#/ Amount Dare Permit/ Invoice# Permit ID# <br /> Code INFO B Remitted rvi Re u # <br /> Glaaa sa3 R pis V w <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />