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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 EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS &6ZI E• j4E7TLGIMt*Vry LAI • CITYfZIP "-01 c?E-L-L4E) <br /> CROSS STREET 7��'J�"'r 1 �y� APN O"f-1 -Z� (I PARCEL SIZE I Yt•6 p <br /> OWNER NAME V ELTM4' Pftc-k/N 3�TTt>J LO S71 YKAV&ptI ) PHONE 3 Ll- L4s3 k <br /> OWNER ADDRESS LOG 2.1 E• 1Z t-;�LEW\&N-) L'N• CRY/STATE/ZIP L-D j->I. c-^ r 2-4 0 <br /> CONTRACTOR L t V t 00p�K &[.O EN V%0ZaN n&LN-wA-L- PHONE 3101 -037 S, <br /> CONTRACTOR ADDRESS -i='L� , w' 0 • - ST • CITY/STATEIZIP "'ot 4'40 <br /> LICENSE C-42 Ot C-36 OTHER P6 NUMBER EXPIRATION DATE 1 3J <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION If <br /> TYPE OF WORK: NEW INSTALLATION ... REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM 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 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 It <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 /> I M4842UR ADY6YCE NOTICE RE IRED FOR INSPECTIONS-PLEASE CALL 009)953-769 <br /> SIGNED TITLE PR's ' MG�' DATE <br /> - - PAY <br /> ew <br /> CFV <br /> i <br /> i D <br /> �- <br /> � 4 <br /> =- <br /> � AQUIIy O2 <br /> RO COVN7Y <br /> 'rAL <br /> — .A - DEPART NT <br /> DEPARTMENT USE ONLY <br /> Application Accepted y I---- 1 /� Date 7 Area Employee ID# T� <br /> Final Inspection By Date SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: 4F - Pit/Sump S it Character: <br /> MMENTS S & r a 3 <br /> S. n <br /> PE SC Received Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remitted ervi eWast# <br /> ICC <br /> -1141 IS <br /> 3,111-11 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />