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t. 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 GALL ZU9 953-7697 FOR INSPECTIONS EXPIRES /1 YEAR FROM DATE ISSUE. <br />JOB ADDRESS 1.'1 CITY/ZIP <br />CROSS STREET VVoc� APN Ogg CSXf� 5 'Z3 PARCEL SIZE <br />l <br />OWNER NAME [`L 4* S�AareyL SeII PHONE <br />OWNER ADDRESS _444 Lr f CITY/STATE/ZIP <br />CONTRACTOR 1111 t, 1-? Is es f G er< ��' PHONE �t SV,��^'�t]� S p, <br />CONTRACTOR ADDRESS �� 6e SO CITY/STATE/ZIP ( y b ­yx-e_4 4--'1- <br />LICENSE ECIC -42 ❑ 'C-36 OTHER jq <br />NUMBER EXPIRATION DATEZo-�- _ <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION <br />❑ PERC TEST # BUILDING PERMIT # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/AD' <br />Coordinates X <br />LAND USE APPLICATION # <br />IN ENGINEER DE <br />REPLACEMENT I OUT -OF -SERVICE SEPTIC SYSTEM I I DESTRUCTION <br />Y <br />INSTALLATION WILL SERVE: ESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY <br />CAPACITY <br />DISTANCE TO NEAREST: WELL ft FOUNDATION <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT <br />TERNATIVE <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />O --'LEACH LINES I LEACHING CHAMBERS <br /># OF LINES _� LENGTH OF LINES t O I ft <br />l <br />DISTANCE TO NEAREST <br />WELL 66'r- ft <br />FOUNDATION .361 ft PROPERTY LINE ft <br />❑ FILTER BED WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />SEEPAGE PITS NUMBER I'- <br />WIDTH 34/ V <br />ft DEPTH 0q<_1 ft <br />DISTANCE TO NEAREST <br />WELL ( 5'6' ft <br />FOUNDATION t{O� 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 <br />2 <br />TITLE !� �.(�a �- f4 (' DATE�-- <br />DEPARTMENT USE ONLY <br />Application Accepted By V1V Date ( z- Area Employee ID# <br />Final Inspection By 9 Date QjQ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />heck <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />W"11 0 <br />115 <br />614E4i <br />7 <br />-300 <br />JW2_ <br />S R00% 4-7 ;t 3 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />