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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 209 953-7697 FORINSPECT/ONS EXPIRES1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS C Pc a CITY/ZIP '11'3o41 1�-1'r�-y <br /> CROSS STREET CH-I�IS[�►'1 FYI APN ZS-0- 1 SC' 2-S- PARCEL SIZE^f(a4e9 A-c. O <br /> OWNER NAME ✓A I.E./V TSN �-os A S PHONE C SIO 1 1 l d ! <br /> OWNER ADDRESS Z�.O( /LE/VTDIV crrY/STATE/ZIP CA 5I Z4y VALLEY, CA <br /> CONTRACTOR O VE OAY- PHONE ��O`►'037 �1`hs`F�° <br /> CONTRACTOR ADDRESS �t- L'l/ ' 0`!`� S f CITY/STATE/ZIP LO7D/t C A <br /> LICENSE LI.'.0-42 J'.',C-36 OTHER C1wy NUMBER 21�1 EXPIRATION DATE Y`3O- 2-2- <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT __ OUT-OF-SERVICE SEPTIC SYSTEM _ DESTRUCTION <br /> INSTALLATION WILL SERVE: _ RESIDENCE LI COMMERCIAL _ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASETRAP 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 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 It 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 it <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 Q110UR ADV E NOTICE RE IRED FOR INSPECTIONS-PLEASE CALL 209)95.3-7697 <br /> SIGNED TITLE PKa� ' ✓n GR DATE (A' <br /> q�MF <br /> FcF,VNr <br /> Fo <br /> �- D E P A RDa eE 6T S ONLY Area S « Employee ID# S Ty�FpMFiy�UN� <br /> Application Ac cepted`By <br /> Final Inspection By ��)W br,1'44 Date (0('LA-1 ❑ SPECIAL PERMIT-Approved by ,RTM� <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: NT <br /> COMMENTS <br /> PE SC Received hec Amount ate Permit/ Invoice# PermitID# <br /> Code INFO ash Remitted Service Re uest# <br /> L)aaa sa3 !So WIL <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />