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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 <br /> hh PERMIT 1/� J <br /> CALL 209 953-7697 FOR INSPECTIONS G,am! ,,+EXP <br /> �IR <br /> �ES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ` V v1 CITY/ZIP o•/1 <br /> �/� <br /> y I/ A -i <br /> CROSS STREET LCnvle - /�►/ /q� 1�A'A,� APN 20 - �DO �o 2 PARCEL SIZE `. �G y <br /> OWNER NAME AKd � WI In �`��rY�'rY1�� PHONE �• U <br /> OWNER ADDRESS /�� 4 n�_e h�Ovl l_� CITY/STATE/ZIP <br /> CONTRACTOR N I K PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑'1C-42 111_IC-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: I! NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> I i REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM X DESTRUCTION 'f ell k <br /> INSTALLATION WILL SERVE: ❑' RESIDENCE ❑ COMMERCIAL C 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 LINEPft <br /> E3FILTER BED WIDTH ft LENGTH ft DEPTH bP.- Y�oj <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH {Tt/ <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH AN IJ Z <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE INC tt <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH CE NTq �I <br /> ly <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE F�T <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 /> S ATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINI HO CE NOTICE UIRED FOR INSPECTIONS -PLEASE CALL 209 953-7697 <br /> SIGNED �Af TITLE 7/lifJ�I� DATE �Zr 3� Zo <br /> 1 <br /> O14 <br /> 0 AL <br /> G h <br /> N <br /> DEPARTMENT U E ONLY <br /> Application Accepted Date 0 dv Area 674 Employee ID# <br /> Final Inspection By Date G SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: <br /> Pit/Sump Soil Character: <br /> COMMENTS ►��� onrPc7�C� �h f�ti r �[L <br /> 1z jan-L <br /> WFI <br /> II / <br /> Vt~ C � �e c n. Gvc. c <br /> PE Sc Received Tt) <br /> Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO BRemitted Service Re uest <br /> yaa + ops r 3 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />