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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 PERMITCALLCALL 209 953-7697 FOR INSPECTIONS EXP <br /> IRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1 2-`-t'-+L/^-�nF 1\ -`f 3(P E• NA>�L y �-�• 7 CITY/ZIP L-0 T.)) I�1'�Q G z ^- <br /> CROSS STREET /t+136AI`-b APN O(07-,2 D - �) PARCEL SIZE +. 6 J At p <br /> OWNERNAME I�LNN(:+�-F Nv3/3^y2--7;> C/o GE-2GE T-ywl S PHONE ((";--C'> 3f'r <br /> OWNER ADDRESS (1Zy S HV7C Vb 5- CRY/STATE/ZIP <br /> CONTRACTOR LIJE OI�'l� GEo�n/✓I✓LONYVt�/J , PHONE 36C( - 037 <br /> CONTRACTOR ADDRESS �� !nJ O A•K ';-F CITY/STATE/ZIP L-OD I <br /> LICENSE ❑iIC-42 ❑❑C-36 OTHER (5G NUMBER Z r EXPIRATION DATE - 0 -1-2- <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # ( BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION [.i REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT II OUT-OF-SERVICE SEPTIC SYSTEM I..i 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 It FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES 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 It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMP$ 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 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 /> MINIMUAMA HOUR ADVANCE N TIC REQUIRED FOR INSPECTIONS-PLEASE CALL 2 7 <br /> SIGNED TITLE f/4F7) ✓"l 6'11`2. DATE .7-�(o- Z <br /> - PAYMENT <br /> RECEIVED <br /> 2021 <br /> SAN JOAQUIN COUNT <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEN <br /> DEPA RTMENT USg ONLY (� <br /> Application Accepted By Date Area I �C Employee ID# D f <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 Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />