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• ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)466-3420 <br /> NON-REFUNDABLE PERMIT L LCALL 209 9$3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 4(,,0a Al' KZAJAJGrjGIG F-1>. CITYtzIP AcAm1P0 9S-2,1- 7 /� �A <br /> (` <br /> CROSS STREET cenfe) APN V I 150-3 lf PARCEL SIZE 2-•ye A`• D <br /> 0 <br /> ^ _ o <br /> OWNER NAME (-A I KZ �V T Z-Int PHONE (R42- -5(RVI <br /> OWNER ADDRESS -Sr�I�1•-r /� 'n' 1 C rTy� CITY/STATEIZIP <br /> CONTRACTOR L-'V` 0AIe' I-L0E(/.�.11ZG*JM N)rAL- PHONE 310 0319' -7 u <br /> CONTRACTOR ADDRESS 4J-1 W. OA(= ST' CITYISTATFIZIP L_U V l CA ��` r0 <br /> LICENSE I C-42 i.IC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> �( PERC TEST #___L_ I FBUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT it DESTRUCTION <br /> INSTALLATION WILL SERVE: -1 RESIDENCE I COMMERCIAL I OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG 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 /> ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL It 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 It LENGTH It 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 It 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 /> MINIMU HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 (0-/1-1 <br /> ,, q <br /> SIGNED TITLE GC/VSLI <br /> V0Yrj T DATE !Y-/1`J 1 <br /> PAYMENT <br /> RECEIVED <br /> 18 2019 <br /> IL I N JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ARTMENTjUS� E <br /> Application Accepted By Date 66 Area mp oyee ID# <br /> Final Inspection By Date —�—L SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cas Remitted Service Re uest# <br /> S <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />