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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR <br /> 2FROM <br /> t DATE ISSUED <br /> JOB ADDRESS !^S,y/T m R LJ IV � 2�T> • CITY(?p ,,,- �11� <br /> T y -1 ! <br /> `T7 JOT y <br /> CROSS STREET PIS N APN 3- -7-Zo- I S PARCEL S¢E 7•S-3 <br /> b 0 <br /> OWNER NAME 1V�/�O W A L AT W A L ZG PHONE / <br /> OWNER ADDRESS 0 I W LI nJN` �D CRY/STATE/ZIP TFC- CA <br /> CONTRACTORL� GEoE/Vy1 RDN E�1 jft L PHONE 3 b 3 S <br /> CONTRACTOR ADDRESS �-I7 W7' o A ST• CITY/STATE/7JP LD-D G S ZA,40 <br /> LICENSE ❑C-42 ❑C-36 OTHER 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 ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT [I 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 gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE To NEAREST: WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES C LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE It <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE To NEAREST WELL ft FOUNDATION It PROPERTY LINE It <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELLIt FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELLIt FOUNDATION ft PROPERTY LINE R <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 /> ]MUM 224�/ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 6 <br /> SIGNED l TITLE r-(PNSV t-rA N'r DATE <br /> 1 I <br /> i I I PAYMENT <br /> ECEIVED <br /> i JUN 18 2019 <br /> ILJL11 1 <br /> --S7N JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> COP TH DEPARTMENT <br /> I <br /> � � l <br /> 2� DEPARTMENT USE 0 LY C <br /> Application Accepted By Date s q Area Employee ID# Pa,r, <br /> Final Inspection By Date ❑ $PECIA 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 PermlU Invoice# Permit ID# <br /> Code INFO By Cash Remitted A Service Re uest# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />