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I 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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 5"Sry � (�//L 'e-'e CITY/ZIP �)� ��f a 34�' <br /> �j h9 <br /> CROSS STREET F'�(' �e�( APN o(i 31D3�s�I PARCEL SIZE <br /> 005, <br /> OWNER NAME � ,py& PHONE <br /> OWNER ADDRESS S/3A94e CITY/STATE/ZIPkzo Cl) G <br /> CONTRACTOR /�ecZJre. ONE �� /-5-Uz7 <br /> CONTRACTOR ADDRESS ��iS� Tt7UdCC/GCW �'/�� 2/G CITY/STATE/ZIP <]✓�� G <br /> LICENSE ❑9-42 ❑ .C-36 OTHER NUMBER �1S ellr EXPIRATION DATE Oaf/�3 <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 /> I REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM L1 DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL Per ) ❑ OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: Pc, NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG /S{7WC, 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 /> i <br /> QL LEACH LINES UI LEACHING CHAMBERS #OF LINES LENGTH OF LINES L�(� ft <br /> DISTANCE TO NEAREST WELL_ &O t ft FOUNDATION ys ft PROPERTY LINE /CIO 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 o1- WIDTH -� ft DEPTH ss ' ft <br /> DISTANCE TO NEAREST WELL_,,&kQ�� ft FOUNDATION 4Q 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 DATE 15— <br /> ^T <br /> / C <br /> D � <br /> DEPARTMENT VS ONLY u <br /> Application Accepted B �'�G.� Date /�� Area 1 qq Employee ID# �� <br /> Final Inspection By Date 7 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS (�,nC�P,fe>'Y✓'lvlf�/I, 1 /riol tL> rem'-;L <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remitted I Service Request# <br /> �ldl� )Isla rs Ou <br /> 4 414//14/18 D ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />