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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�AjLL 209 953-7697 FOR INSPECTIONS / EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS U IGp�C CITY/ZIP r <br /> _ H <br /> CROSS STREET 0 Pao-01 )I APN ©f R U 3 07.2 PARCEL SIZE 0 �y <br /> /64� <br /> o <br /> OWNER NAME rS� 'I J �CT_ PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR LXi�/I r��I 17Va`��'/ �C PHONE �O c�CO /L/ t /1�7 G g <br /> CONTRACTOR ADDRESS / 7� h /'l�� ►/✓ CITY/STATE/ZIP ✓��'^'/II�! (� !��[ / <br /> LICENSE ❑)&2 ❑I;C-36 OTHER NUMBER yS9o45 EXPIRATION DATE !/3ID 073 <br /> T� <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION C ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT 11 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 1 rZ Q U gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL O ft FOUNDATION /O ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> L,!( LEACH LINES U LEACHING CHAMBERS #OF LINES LENGTH OF LINES O S ft <br /> DISTANCE TO NEAREST WELL 4So 4—ft FOUNDATION ` O / 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 \3 / WIDTH / ft DEPTH ��' ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE /O 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 NO WE REQUIRED FOR INSPECTIONS -/PLEASE CALL 209 953-77697 <br /> SIGNED TITLE l� i"o/l/a!j� DATE <br /> UID <br /> J <br /> RDIM <br /> M <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Cry J Area qM Employee ID# / S <br /> Final Inspection By (`of't,Lu(off.-t C' Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS I'J vJ SFR T",'p,- i- <br /> PE SC Received heck#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Remitted Service Request# <br /> 4a 11 117 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />