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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 CALL <br />209 953-7691 FOR INSPECTIONS tXPIRES 'I TEAR FROM UATE 155UEI <br />JOB ADDRESS9 <br />CROSS STREET <br />L-1 2 11 <br />TYPE OF WORK: NEW INSTALLATION <br />CITY/ZIP <br />APN O 6 1 C)CIO � PARCEL SIZE ),3L <br />AA JAS <br />A/' C C� vl 1`7 <br />OWNER NAME <br />Al i.1 f n � ' 00 ' " Oi/z <br />I (J <br />/ <br />(. � Lr •{ <br />PHONE <br />OWNER ADDRESS <br />rJ <br />CITY/STATE/ZIP <br />CONTRACTOR 6-41lira/ <br />CONTRACTOR ADDRESS ✓ / �3u <br />LICENSE ❑X-42 ❑LIC -36 OTHER <br />PHONE vP(,, % r -3-362l 15-09 7 <br />' "T, - CITY/STATE/ZIP itk <br />NUMBER rS(yEXPIRATIONDATE <br />O- X -J a ...... rnn.A;G +e V <br />V <br />I <br />❑ <br />PERC TEST # <br />BUILDING PERMIT # cl 10 LAND USE APPLICATION # <br />L-1 2 11 <br />TYPE OF WORK: NEW INSTALLATION <br />i l REPAIR/ADDITION 1 ENGINEER DESIGNED /ALTERNATIVE <br />❑ REPLACEMENT <br />I I OUT -OF -SERVICE SEPTIC SYSTEM l I DESTRUCTION <br />INSTALLATION WILL <br />SERVE: ❑ RESIDENCE <br />❑ COMMERCIALJ OTHER <br />(NUMBER OF LIVING UNITS: <br />NUMB/ER OF BEDROOMS: (/ " NUMBER OF EMPLOYEES: <br />SEPTIC TANK <br />TYPE/MFG <br />CAPACITY /C gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP <br />TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION O ft PROPERTY LINE P r ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ND OIL SEPARATOR (ENCLOSED SYSTEM) <br />2)4 <br />' <br />Lf 0 <br />LEACH LINES <br />11 LEACHING CHAMBERS <br /># OF LI LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL <br />< ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />FILTER BED <br />WIDTH ft <br />LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />❑ <br />MOUNDED <br />WIDTH ft <br />LENGTH ft DEPTH i <br />1� <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION PROPERTY I IMF !n ft <br />Al <br />DISTANCE TO NEAREST <br />DISPOSAL PONDS WIDTH <br />DISTANCE TO NEAREST <br />SEEPAGE PITS NUMBER <br />DISTANCE TO NEAREST <br />WE4LC- <br />ft LtNGTH ft DEPTH <br />WELL .._eft FOUNDATION ft PROPERTY LINE ft <br />WIDTH I ft DEPTH ft <br />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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED TITLE «b DATE i7 —4* — L <br />` DEPARTMENT US& ONLY <br />pli ftlon ccepted Z--/-- Date 7 1 Area t �l Employee ID#� <br />Final Inspection By Date ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft. Pit/Sump Soil Character: <br />COMMENTS Fsz: l -7 -.'Py- ff <br />PE <br />Code <br />SC Received C,Chec <br />INFO B Cash <br />Amount Date Permit/ Invoice # Permit ID# <br />Remitted Service Request # <br />L-1 2 11 <br />j)-7 .2 <br />519 11,911 &1 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4114/18 <br />T <br />