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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/ ,/EX�PJIIRESI YEAR FROM DATE ISSUED <br /> JOBADDRESS 76-4 OA,-r Faur2 <br /> arN CITY/ZIP �CI'I (If"W rys27/ y <br /> y�,.. , Q 7 n <br /> CROSS STREET )CT26A1 GrL7 �/¢'1YJP Q0/40 APN PARCEL SIZE q <br /> OWNER NAME NOG E Tp/ F/.A/7{`�s �lAECL9.�X��fA PHONE .2e f -402^4 fel <br /> OWNER ADDRESS f��• y OJC J?��j- /nY � 7 CITY/STATE/ZIP <br /> CONTRACTOR��SAA1 e V fIf ojSlz z j-/��N�� PHONE <br /> CONTRACTOR ADDRESS I © D oy 71-r CITY/STATE/ZIP <br /> LICENSE ❑I IC-42 ❑ C-36 OTHER IZC95 NUMBER EXPIRATION DATE G 30-a0,�e? <br /> WA <br /> T TABLE DEPTH: 7— ft GEOGRAPHICAL INFORMATION: CDordinatos X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: LI NEW INSTALLATION REPAIR/ADDITION Li ENGINEER DESIGNED/ALTERNATIVE <br /> U REPLACEMENT i OUT-OF-SERVICE SEPTIC SYSTEM Cl DESTRUCTION <br /> INSTALLATION WILL SERVE: 1 RESIDENCE I 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 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 0 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 It 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 /> MINI 48 H DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE eMIZ- "/N,EE,'? DATE 14111 ZL!5� <br /> Am <br /> T J <br /> o w cc RC A/& C01/ <br /> aAf <br /> T <br /> P A R T M E N T LISE ONLY <br /> Application Accepted By Date / Area Employee ID# <br /> Final Inspection By Kms' v Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to De of 3 Ft: Pit Sump Soil Character: <br /> COMMENTS �Q. r 13, ry\-k,,z II c <br /> PE SC Received G Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO BV Cash Rernitted Service Request# <br /> lL-12.S <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />