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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/-76)97 FOR INSPECTIONS EXPIRES,p1`YEAR FROM DATE ISSUED <br /> JOB ADDRESS 12 SO([' /Z IJA Y CITY/ZIP ,�� jaLOi�l J! 3Z 0 Z <br /> CROSS STREET J!� �/� APN c5205-' /O-e2 PARCEL SIZES gs/ <br /> OWNER NAME L OS e VILL A�LZI.(�� PHONE,27L 4- 615-96OWNER ADDRESS _34-1-7 JA K,9TA CITY/STATE/ZIP R1 V,5rZ SAN/-. ('A q,E 36T <br /> CONTRACTOR Do CpNE�tFE PHONE <br /> CONTRACTOR ADDRESS I L30S( 3714 CITY/STATE/ZIP <br /> LICENSE EY C-42 111-IC-36 OTHER NUMBER 764-7q EXPIRATION DATE 4��D�o2/ <br /> WATER TABLE DEPTH: A) ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # / BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIRIADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: C 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 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 f1 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH A 0 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LI E'N u 414317 ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTFIHFeNV/Rn IN �jyft <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 ORDINAN ?, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINI"U 48 6 ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 953-7697 <br /> SIGNED TITLE G/I//L J=AIC7/N cF/? DATE e11276 rZ1j <br /> R Tr <br /> } <br /> LU <br /> y� DEPARTMENT USE ONLY <br /> Application Accepted By `�� Date _ �b w<: Area Employee ID# S K <br /> Final Inspection By �Y�-74r Date �� '�� E SPECIAL 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 Permit/ Invoice# Permit ID# <br /> Code INFO B Remitted Service Request# <br /> ad(w) 5a3 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />