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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 <br /> nr �-y CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I,?QJo IV. /ta��/ +y �qJ CITY/ZIP ��, gSL�fL Z <br /> CROSS STREETi„K��pry �/� APN OSS_/IlrQ - L 3 PARCEL SIZE <br /> OWNER NAME dP/V/� �Ic�Bn/A/t L. �L�/�/�j PHONE <br /> OWNER ADDRESS �S C� //7U- jry►//ON �() - CITY/STATE/ZIP7/ ,(L�j� // � <br /> CONTRACTOR (�[,'� �( UNST����N c PHONE � /( / l/ -�7C/�/ (7 <br /> CONTRACTOR ADDRESS -7 S Z S J7rYCf / CITY/STATE/ZIP v ` 7S <br /> LICENSE ❑ C-42 ❑ C-36 OTHER NUMBER 75 69 EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND 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: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ♦ {�(�T;t gTANK TYPE/MFG �Iucast�wcm4c CAPACITY 2,00 <br /> gal #OF COMPARTMENTS OMe. <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY // gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL Zao( ft FOUNDATION l0.6r ft PROPERTY LINE IS4` 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 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 /> 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 H ADVAN E NOTICE RE IRED FOR INSPECTIONS - PLEASE CALL 209)953-7697 <br /> SIGNED TITLE� DATE <br /> 44, <br /> JNWE <br /> 1 <br /> N p QU N 1,0 <br /> E V E T <br /> EPARTMENTIJSECNLY , <br /> Application Accepted By Date Area Employee ID# <br /> Final Inspection By Date 0 SPEd�AL PERMIT-Approved by <br /> Character of Soil to/Depth of 3 Ft: PiVSump Soil Character: <br /> COMMENTS <br /> std o 0 <br /> i <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO A 9Y I Cas vRerlriitted Service Re uest# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />