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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 3 5-1 1 J AV%,\Ir: CT. CrrY/ZIP N C&mf-'O y y <br /> H <br /> CROSS STREET V�y'%j�1�C*C� APN cc s-- 3 3 a- o PARCEL SIZE 2"o( ', o <br /> OWNER NAME FIy•"-7 1'�/S G � �i��l�i^ l�o;r-�J`� PHONE (s16) 3Rk-cicL�{� m <br /> y <br /> OWNER ADDRESS �hm�1C� �S CrrY/STATE/ZIP <br /> CONTRACTOR 1-(J1 O�`r �L O E, ��Q�`'�m�N 1�1�L- PHONE 3(. -o Y) <br /> CONTRACTOR ADDRESS '?O, w . <br /> qqo'�� ' CITY/STATE/ZIP L'OD%. <br /> LICENSE Ell-IC-42 0')C-36 ` <br /> 6 OTHER e NUMBER Z 5-1 EXPIRATION DATE -3�-ZZ <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: 0 NEW INSTALLATION 0 REPAIR/ADDITION 0 ENGINEER DESIGNED/ALTERNATIVE <br /> I REPLACEMENT I..I 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 /> ❑ 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 It <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 It LENGTH ft DEPTH ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE To N EASIEST 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 /> I HEREBY CERTIFY THAT 1 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 /> SIGNED TITLE ►�20,1 ✓� G'R- DATE I'7- <br /> Rk ���Af/ <br /> 10�ogQU02 2020 <br /> H p NMECOUNTY <br /> Ep,�TM NT <br /> l' DEPARTMENT USE ONLYDA <br /> Ll <br /> Application Accepted By I Date 3 1/�o:°n Area Employee ID# _ <br /> Final Inspection By Date C SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Chec Amount Date PermiU Invoice# PermitID# <br /> Code INFO ash Remitted Service Re uest# <br /> -13 7-7-5 1 fIQ 'Ll'i'o <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14118 <br />