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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE P RMIT iCALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITYIZIP 11� <br /> f n,, m <br /> CROSS STREET ea 1 I V APN 0 b 7 a�o J 6 PARCEL SIZE It� 3� d <br /> d <br /> OWNER NAME Ze&del PHONE <br /> OWNER ADDRESS . VI F CINISTATEIZIP <br /> CONTRACTOR diev PHONE ��t'1� /��`y,� <br /> CONTRACTOR ADDRESS �✓ N ."`VLK CITYISTATE/ZIP � 21A C, 1 <br /> LICENSE ❑�C-42 ❑-]]C-7-��36 OTHER NUMBER_ E%PIRATION DATE <br /> WATER TABL/'E``DEPTH: ��^y I3V ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: L NEW INSTALLATION REPAIR/ADDITION = ENGINEER DESIGNED/ALTERNATIVE <br /> L, 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 /> S EPTIC TANK TYPE/MFG /.S I'N'1 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 C LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL /OC•, ft FOUNDATION .>0 ' It PROPERTY LINE �� ft <br /> ❑ FILTERBED 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 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO REST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER WIDTH 3 r ft DEPTH -� _ ft <br /> DISTANCE TO NEAREST WELL-L-5 O' ft FOUNDATION YC ft PROPERTY LINE 30 It <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 48 HOUR ADVANCE NOTI E REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 ]/ <br /> SIGNED TITLE l DATE Z <br /> YMENT <br /> BCB ' 7 2021 <br /> AQUIN COUNTY <br /> IRONMENTAL <br /> H DEPARTMENT <br /> L' DEPARTMENT USE ONLY t� <br /> Application Accepted By Date / Area Employee ID# D A <br /> Final Inspection By Date 2 1 1, ElSPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENT Fe%dule t llr)Ps I/n✓ t 'Ie 11'. ;.II t ►h .5fA"licks Per FA <br /> I(e c o refs <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Permit lD# <br /> Code INFO j3y. gash If Remitted j Se uest# <br /> ice Re <br /> old I i l5' I 30 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />