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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 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS �C�U (0 ff14 CITY/Zip <br />r�/ �L fi''''r <br />CROSS STREET \ ��7�/L—iT�i�l. APN ( / / _5200 0 Lv PARCEL SIZE -40 0 *_{Ices <br />OWNER NAME atLs oe{i PHONECUC7) 5-.7S " 15"42— <br />OWNER <br />54`OWNER ADDRESS C, CITY/STATE/ZIP p <br />CONTRACTOR St � Ceo1 AS� v(_71 � A �5�� t PHONE �G��� ^Zt�(8"-- 3�� <br />CONTRACTOR ADDRESS �b60 U)AIG([Zi�II W / p+� C,( CITY/STATE/ZIP ` IN�TW7 CA,) <br />LICENSE RIDC-42❑ ❑C-36 OTHER NUMBERT3 J � 7T S EXPIRATION DATE <br />WATER TABLE DEPTH: `� _ % ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: 11 NEW INSTALLATION El REPAIR/ADDITION n ENGINEER DESIG D /ALTERNATIVE <br />REPLACEMENT �C- ❑ OUT OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL '❑ OTHER r L <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY <br />CAPACITY <br />DISTANCE TO NEAREST: WELL ft FOUNDATION <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />M <br />Application Accepted By <br />Final Inspection By <br />Character f Soil DeA- <br />-0 <br />th of 3 Ft: <br />COMMNTS L� 10 <br />01411, 14 <br />gr'l 1A dq <br />T. <br />H <br />[+7 <br />O <br />C <br />41 <br />� DEPARTMENT USE ONLY'�� <br />Date 114 znz!Area Employee ID# <br />Date -o% ?d 2_1 ❑ SPECIAL PERMIT -Approved by <br />PiVSump Soil Character: <br />sevf?�_Y� or CC ;1 <br />mom <br />A <br />PE <br />Code <br />LEACH LINES <br />LEACHING CHAMBERS i PI -CI I -f If4Z-a-O�S # OF LINES <br />2- LENGTH OF LINES [D_ O / ft <br />Amount <br />Remitted <br />Date <br />r <br />Invoice # <br />Permit ID# <br />Z 4 <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />FILTER BED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft>F1C� JDATION <br />ft PROPERTYLINEft <br />SUMPS <br />WIDTH 4- ft LENGTI;I, `y <br />ft DEPTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH ft <br />['Z1� we1j <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />I HEREBY CERTIFY THAT <br />AV`k 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 />MINIM M 48 HOUR ADVAN E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)J953-7697 <br />SIGNED <br />TITLE <br />DATE <br />Application Accepted By <br />Final Inspection By <br />Character f Soil DeA- <br />-0 <br />th of 3 Ft: <br />COMMNTS L� 10 <br />01411, 14 <br />gr'l 1A dq <br />T. <br />H <br />[+7 <br />O <br />C <br />41 <br />� DEPARTMENT USE ONLY'�� <br />Date 114 znz!Area Employee ID# <br />Date -o% ?d 2_1 ❑ SPECIAL PERMIT -Approved by <br />PiVSump Soil Character: <br />sevf?�_Y� or CC ;1 <br />mom <br />A <br />PE <br />Code <br />SC <br />INFO <br />ReceivedCheck# <br />By <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />Z 4 <br />zZ 2 <br />3 <br />SR00 844 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />