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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 p CALL(2-w09 953-769/7 FOR INSPECTIONS�p � EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS '2-11419 S• C 61"�y�L 11�LLO VO ttl> CITY/ZIP 1 f'*C 4 1'9'rL+ L <br /> CROSS STREET GLOVE• APN 7'1X 7-100�0'Z PARCEL SIZE 1'66 P• o <br /> �y� 1 �W 0 <br /> OWNERNAME �A'RJfAJAE2. K„`I ydrj PHONE_�Zf �Z� y <br /> OWNER ADDRESSyf-u e 'e't,)"It D'r CITY/STATE/ZIP �IG�.L� 977 y <br /> CONTRACTOR L•IVC URIC, PHONE 369-0315 <br /> CONTRACTOR ADDRESS LjO1 v.)- 0AV- ST . CITY/STATE/ZIP LOO t GA e S Z4O <br /> LICENSE L C-42 U'. C-36 OTHER C6r NUMBER 2-15" EXPIRATION DATE 4—3c-2-2- <br /> WATER <br /> Z2WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # 1 BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION _ REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I: DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE 11 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 It 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 It 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 ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH It 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 /> 1 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 /> MINIMUM jOr NENOTICE RE RE R INSPECTIONS-PLEASE CALL 209)953-7697 <br /> SIGNED TITLE P2ts� ✓►�Cr2• DATE CI - <br /> S <br /> l ENT ry <br /> / DEPARTMENT USE ONLY TMENT <br /> Application Accepted y �� Date ea Ch Employee ID# _ <br /> Final Inspection By l " Date 1 n/1 7/ZO SPE AL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pi�t/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# PermitID# <br /> Code INFO B ash Remitted Service Re est# <br /> as a #►sa 2 2 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />