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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCK70N CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Zcl, (o -* Zo3o& 1-7, �IV�(L IZ Lam- CITY/ZIP fzl Pct �S3(�(v <br /> CROSS STREET V pv-Yj GSL r j APN 2`f� -Z3 0 -L4 3 rP_ARCEgL SIZE 1 I.,F-`-` <br /> OWNER NAME �I "�' '� PHONE_ lXZ (q- !T '�y <br /> OWNER ADDRESS Z C-3C (P �V t}L IZ7- CITY/$TATFJZIP <br /> CONTRACTOR L_kV E DSI` PHONE 3U-2 —C3-1r <br /> CONTRACTOR ADDRESS 44C--i r�- - L) is;—( CITY/STATE/ZIP I/C�:>( C-VC\ '�-2---�C) <br /> LICENSE ❑IIC-42 ❑0C.36 OTHER Ce-6,- NUMBER 2-15 ( EXPIRATION DATE Z4-30 -ZZ <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # Z- BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION a ENGINEER DESIGNED/A' <br /> �] REPLACEMENT OUT-OF-SERVICESEPTIC SYSTEM C 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 i::i 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 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 ft PROPERTY LINE ft <br /> 1 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 /> MINIMUM48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE P2cr' ��V(L DATE -ZZ-2- <br /> i <br /> I <br /> ;*A17 <br /> J <br /> T 7-y <br /> T <br /> DEPARTMENT-USE ONLY <br /> Application Accepted By ZiG— Date 0'I3n/J 1 Area L4 I Employee ID# r1 C <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received (CAmount Date Permit/ Invoice# PermitlD# <br /> Code INFO B Remitted Service Request# <br /> H +30`-I 2.22.21 5QOOg <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4114/18 <br />