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c <br /> 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 /> 11 II �' -- {�JCITY/ZIP <br /> JOB ADDRESS W�y 64'Ar <br /> M l / <br /> CROSS STREET l�wN 3 3 APN Z �� / / PARCEL SIZE O I 1 <br /> .r _ c <br /> OWNER NAME NITN JeRAAJa44?. ^4 <br /> M k V' l� PHONE <br /> I �71� G� t7' v. <br /> OWNER ADDRESS 31+ 00 S. ko4me- "arA CITY/STATE/ZIP 7'VZr4e'q 044-` q/QST� <br /> CONTRACTOR QVI09 *)Ceg&jnqM NJ � [J►!r`0 �L PHONE d) <br /> CONTRACTOR ADDRESS T"J ?�>K CITY/STATE/ZIP <br /> LICENSE 0-C-42 111IC-36 OTHER 4,4 67" NUMBER EXPIRATION DATE <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 Elf GLNEER DESIGNED/A TERNPTIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION ��h I <br /> INSTALLATION WILL SERVE: C RESIDENCE ❑ COMMERCIAL C 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 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 /> M1NhXVM 48 HOUR ADVANCE NOTICE REQUIRED FOR INS CTIONS -PLEASE CALL 209 953-7697 <br /> SIGNED TITLE 7) t DATE '7 <br /> InT <br /> 0 <br /> v► o u ry <br /> DE:qWiAr <br /> DEPARTMENT USE ONLY L <br /> Application Accepted By Date -7 ) Area S �� Employee ID# ��Y I <br /> Final Inspection By 144 Date a C C SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth o 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS /'f a RUM - �Pc 4 dpw -b " P 4'd r S 4W is a 64kt 6, <br /> 4- S i L. j-,e- -4r-e 2 s i(- s bo�� s us-f- <br /> re P 1 I o S d Selo lL �' des-Iyv c( -�- s <br /> PE Sc Received hec Amount ArmiU <br /> Code INFO B ash Remitted Date Service Request# Invoice# Permit ID# <br /> 221 - '2- <br /> 42-01 PLAVIIAP reC.¢A+P4- Gt4{-RLi �� <br /> V1C > C 4C tv • ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />