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'0i' w ONSFE W,ASTEWATER 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 /> JOB ADDRESS 75 u/ S. L a�mm crS^ / CITY/ZIP - /�GLCL1 f S�U <br /> ny <br /> CROSS STREET �V`�e- �r- APN PARCEL SIZE b <br /> d <br /> 7� <br /> OWNER NAME )ti G(�l��U PHONE <br /> y <br /> OWNER ADDRESS CITY/STATE/ZIP OQ <br /> ` <br /> CONTRACTOR O.�P�{�IZ-2 Q LD r\ 5k l^& L 4i Qyn T��ll1 C r PHONE _ZO Qi 1 <br /> CONTRACTOR ADDRESS J L a(� 'C i S"� 1"� ` C CITY/STATE/ZIP <br /> LICENSE CLIC-42 ❑LIC-36 OTHER—b- �7 NUMBER � e)1 EXPIRATION DATE y <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: C NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> 2K REPLACEMENT n OUT-OF-SERVICE SEPTIC SYSTEM 'NC' DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL �J ❑ OTHER <br /> NUMBER OF LIVING UNITS: / NUMBER OF BEDROOMS:_ J NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG L ifZZI CI-&�� CAPACITY _p� _ gal #OF COMPARTMENTS <br /> © GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 0 LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 0 LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 0 FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> Cil MOUNDED WIDTH ft LENGTH_ ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH r"AyME ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY U J' ft <br /> G7- <br /> U DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH — ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY L $ �I�7� ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTHeSA�N�`JOA^... - � ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION- - ft— PROPEF'__' -RONpM�ep"y��VNN ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COU7NTY OR'19R �ES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM48HOUP ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 953-7697 <br /> SIGNED TITLE `-_� <.I!�UYI7Y-, DATE (�0 8 ^o7�Jy2O <br /> 1 <br /> V f <br /> D PARTMENT USE OIAYILY � n <br /> Application Accepted By Date Area Employee ID# <br /> �T Y�r� <br /> Final Inspection By Date t ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/S}I p Soil Char Iter: <br /> COMMENTS i/—� IT O (3 (" D <br /> Sem-p��ppc 0 DO, r C_c R_Q '✓(s+e12 qf- co-yi n --6-1Lt `-d se ver <br /> ti�a'' 2�011.1(�Pn <br /> PE SC Received C Check Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Remitted Service Request# <br /> 2 � 2U S ti (a5 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />