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r <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 EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS IDU/ �,nf f W 7 (9 Q CITTY/ZIP 2 2,6-33,65, ^ Z' <br /> CROSS STREET rrel,f' l G[0"0 IQ Dad AP PARCEL SIZE <br /> OWNER NAME ly , tV (1�1C /-� 11 /�J PHONE Dn7' ��0j 5-- <br /> OWNER ADDRESS a n S {1 w ! - - CITY/STATE/ZIP /)��QYI�CG C A ! 5 3 <br /> CONTRACTOR T 1 L1�1 /`� �,D n)5-rie I C / . D A) PHONE �0/,-115/9 S- 0 S SnS <br /> CONTRACTOR ADDRESS �U Cn llen V- �U r c CITY/STATE/ZIP f1ade�n C�4 7 53b O <br /> LICENSE [11-IC-42 ❑'_iC-36 OTHER NUMBER yI37/ ( EXPIRATION DATE <br /> WATER TABLE DEPTH: L f'lJ r 'T� It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> 1 <br /> ❑ PERC TEST # BUILDING PERMIT#I 6P-190c),7.31LAND 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: 1-1 RESIDENCE I I COMMERCIAL 1 OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: j NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG _ CAPACITY �O✓ gal #OF COMPARTMENTS <br /> GREASE TRAP TYPE/MFG CAPACITY C gal #OF COMPARTMENTS <br /> DISTANC TO NEAREST: \NEIL ///0b 1 ft FOUNDATION /� It PROPERTY LINE ft <br /> LIFT STATION SIZE 1 TYPE OF PUMP m 13PKG TX PLANT L3SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> � �c7 C�-�,t�a,•r <br /> Tom _ s <br /> LEACH LINES LEACHING CHAMBERS #OF LINES / LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL _ OO It 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 It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH fl DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH It 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 It PROPERTY LINE 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 /> MINVUM48HQVRADVA CE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 953-7697 q <br /> SIGNEDj -A TITLE 0w'n P/ DATE <br /> AJO J114 <br /> NIAEtITAI <br /> HEW EARM N <br /> PARTMENT SE NLY <br /> Application Accepted By _ Date Area Employee ID# <br /> Final Inspection ByNA I Date SPECIAL PERMIT-Approved by <br /> Character of Soil to D pt 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO IV Remitted Service Request# <br /> S► 31 L4 I <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />