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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCK70N CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Z•�Z 1 S yP,b GC-.4-- �L . I q CITY2UG! 0 <br /> 1P S� I,1 1 S Z 05— <br /> CROSS <br /> 5CROSS STREET lC.i l..��I 7 API 12-0 — 0At <br /> � �PLA�RCEL SIZE �'!0 <br /> OWNER NAME •' �' K/K1 D 1 D PHONE 1+0 10 <br /> OWNER ADDRESS Src vri CrrY/STATE/ZIP <br /> CONTRACTOR LlytUa� yEO E�VI R•{){�M�NT�Y L_ PHONE C) q <br /> CONTRACTOR ADDRESS 4o ) L-i O�K ST' • CRY/STATE/ZIP L'� L C—A `7)Y2-'40 <br /> LICENSE ❑I IC-42 ❑ / <br /> ❑C-36 OTHER C Ey NUMBER 2-1 I EXPIRATION DATE 4130 -17- <br /> WATER <br /> 130 -y7- <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # L BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> 1.1 REPLACEMENT I.] 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 /> ❑ 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 It <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES L:! 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 It PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ $UMP$ 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 NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It 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 /> MINIMUM,48 HOUR AZWANCE NOTICE REQUIRED FOR INS <br /> PECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED - - -�'�-'L TITLE /�O�J• H'l G'I� DATE -3 <br /> 1 <br /> J� <br /> � r09 <br /> Zp21 <br /> pMEIyT �Y <br /> l DEPARTMENT.0 E ONLY �rME/VT <br /> Application Accepted By - ���L� Date 3 4 Area Employee ID# DA <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 Check Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash Remitted Service Request# <br /> LP2 3t !s2 p 1 M P:92 5AI121513,00233-78 <br /> V1 I <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />