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z <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 /1 CALL 209 953-7697 FOR INSPECTIONS ExPIi�RES 1 YEAR FROM DATE ISSUED <br /> � r <br /> JoBADDRESS . yVo U . �/ 1 I � J CITY/ZIP <br /> I n cj� /t� —7 (� l� <br /> CROSS STREET ����� 1�� APN 0(� ( ©��" �� PTARCELS2IZE �/� C <br /> OWNER NAME �I1�t�-T \ � C,a L J I PHONE d e/� ;5J11 V'1 71 1 <br /> OWNER ADDRESS -1 7V �W l(4 J �,J CITYISTATE/ZIP / c -m VC) <br /> //�� <br /> CONTRACTOR L-C_Nj IkL,\t I,1✓J PHONE x`1 �p�I,,.JJ <br /> CONTRACTOR ADDRESS ��/ 1� `EfiYl, 1�1J CITYISTATE/ZIP �J—AA-(7) <br /> LICENSE ❑❑C-42 110C-36 OTHER NUMBER EXPIRATION DATE <br /> 1 <br /> WATER TABLE DEPTH: 0 — 1 ZD ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION## <br /> TYPE OF WORK: NEW INSTALLATION L REPAIRIADDITION Ll ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: %AESIDENCE ❑ COMMERCIAL 1 ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> /� <br /> C <br /> SEPTIC TANK TYPE/MFG CAPACITY G J 0 gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG 1 CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL V ft FOUNDATION ft PROPERTY LINE ft <br /> ❑/LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT !�❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 0� LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES / ft <br /> [1 / <br /> DISTANCE TO NEAREST WELL,, 17y ft FOUNDATION (u ft PROPERTY LINE •(P-0 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 NEWES �T WELL ftFOUNDATIONft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER � WIDTH p t I ft- <br /> DEPTH ` ft <br /> DISTANCE TO NEAREST WELL 2:0U -� ft FOUNDATION /) I ft PROPERTY LINE /( L) -�- 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 /> MO ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 953-7697 (� <br /> SIGNEDZk� TITLE QW N Q& DATE <br /> IVNT <br /> Fo <br /> ,, 2019 <br /> RU <br /> TA4 <br /> FNT <br /> EPARTMENT SE NLY <br /> Application Accepte By Date Area Employee ID#� <br /> Final Inspection B Date ❑ SPEPE IA IT-Approved b <br /> p Y PP Y <br /> Character of Soil to Depth of 3 Ft: Pk/Sump Soil Character: <br /> COMMENTS ' <br /> L <br /> PE Sc Received rphacWl Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By_ ash Remitted Service Request# <br /> l 353 � S <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24/12 <br />