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s <br /> 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 209 953-7697 FOR INSPECTIONS T� EXPIIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Z2-1-7 W. <'A, 4t6rCNT P-]>. CITY/ZIP Ct,V) <br /> CROSS STREET DPf� APN O ZS-` ' 4U PARCEL SIZE I J Z a <br /> 0 <br /> OWNER NAME Z A C_ tZ u-k S PHONE tyS.t 303-o,;- <br /> OWNER ADDRESS ,�11n'' C. c�yNfEjD�ruwlSElTJS LCITY/STATE/ZIP S&L.tA (=A <br /> CONTRACTOR PHONE 311 -o3l S <br /> CONTRACTOR ADDRESS 'yv, w- OAK S-r- CITY/STATE/ZIP L-0-DI C-A CIS-2-40 <br /> q1S240 <br /> 41 <br /> LICENSE -'—C-42 0:1 C-36 OTHER C�s NUMBER I r( EXPIRATION DATE -3 _2Z <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT _ OUT-OF-SERVICE SEPTIC SYSTEM _ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL V 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 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It 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 /> MINIMLIMin URA12VAN NOTICEREQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-769 <br /> SIGNED TITLE DATE <br /> AYMENT <br /> 14 ECEIVED <br /> B 0 1 2021 <br /> SANJOAQUIN COUNTY <br /> IRONMENTAL <br /> HEALTH DEPARTMENT <br /> / DEPARTMENT S ONLY j <br /> Application Accepted By — �G L Date � Area Ll Employee ID# 5 <br /> Final Inspection By Date SPECIAL PERMIT-Approved by <br /> Character of Soil to Dept of 3 Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Receiv d Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Cash Remitted Service Request# <br /> IV R-4,51 5a 3 l sa 94-1-1 <br /> 2?-O <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />