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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1(� W• (jOVj MAIQ CITYMP Fq F-1VCtk Cftt, .p of SS 2-31 <br /> TT qH <br /> CROSS STREET -j•---S APN /3- Z 100 I PARCELSIZE )'S �• o <br /> OWNER NAME 5AL- SCr4"A PPHOC S -1 <br /> ONNEE <br /> I 0) /(,,o- 3(C <br /> OWNER ADDRESS I S•,s- E�DW Pc'2.� -• CrrY/STATE21P 1 r'••��`�� c.A 9 S31 <br /> CONTRACTOR Ll-JE CJ�< G00EalyIR0,.JrVgaW iL, PHONE 3VF-031 p <br /> CONTRACTOR ADDRESS '401 W- C)^-W- .Sr• CITY/STATE/ZIP L D I CA <br /> LICENSE ❑I7C-42 ❑17036 OTHER C G NUMBER Z ( ExPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST #___L_] BUILDING PERMIT# LAND USE APPLICATION# j <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION 0 ENGINEER DESIGNED/ALTERNATNE <br /> -.. REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM 0 DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG 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 It LENGTH it 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 It DEPTH ft <br /> DISTANCE TO NEAREST WELL It 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 /> MINIMUM OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNEDAa <br /> TITLE PQ•o) vVXCs2• DATE Z-E-- 2 <br /> // DEPARTMENT USE ONLYIy'14h�y <br /> Application Accepted By �L Date Tl Employee ID# <br /> 7 Area <br /> Final Inspection By Date 0 SPECIAL PERMIT-Approved by T <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received LC,eow Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remitted Service Request# <br /> a�a 53,1A rA yrs •7• S12, 2 <br /> L) w <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />