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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-KEFUNDABLE PERMIT (:HLL (LUY) 90J -/6y/ FOR INSPECTIONS LXPIRES 'I YEAR FROM UATE ISSUE <br />JOB ADDRESS <br />1,16-111) / re' <br />c CITY/ZIP 1-cat-, &✓ t <br />CROSS STREET <br />`yn <br />LO �� <br />APN ' I 7 <br />PARCEL SIZE <br />OWNER NAMEV'� <br />1 i i )-1 <br />f C / IGI ✓f 3 vl C J tj <br />PHONE <br />OWNER ADDRESS <br />-7p <br />/ L` S YC fAe W,-, v <br />CITY/STATEIZIP,G� <br />OTHER <br />CONTRACTOR <br />&-4-0 I C <br />PHONE ; <br />% 3ti� el <br />3, <br />CONTRACTOR ADDRESS [ � ��7 <br />l <br />% '� 1. CITY/STATE/ZIP <br />t� �6 i, <br />LICENSE ❑ ijG-42 ❑ ❑C-36 OTHER <br />NUMBER EXPIRATION DATE <br />�j <br />/ J-) _,2� <br />/ <br />16(-) /� <br />WATER TABLE DEPTH: q 100 ft <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />❑ PERC TEST # <br /># OF LINES � <br />BUILDING PERMIT # 710195�ir LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION <br />i.I REPAIR/ADDITION <br />❑ ENGINEER DESIGNED /ALTERNATIVE <br />Ci REPLACEMENT <br />❑ OUT -0F -SERVICE SEPTIC SYSTEM <br />❑ DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE <br />❑ COMMERCIAL ❑ <br />OTHER <br />NUMBER OF LIVING UNITS: I <br />NUMBER OF BEDROOMS: y2 <br />NUMBER OF EMPLOYEES: <br />" SEPTIC TANK TYPE/MFG (Cr <br />p, L CAPACITY /fit / <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />ft <br />/ <br />16(-) /� <br />30 <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF <br />PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - /jPLEASE CALL 209 953-7697 <br />SIGNED TITLE <a, , ✓4C1'Z'"- DATE lQ ' // _ "; / <br />��y� / DEPARTMENT US ONLY Q y, <br />Application Accepted By f G Date /� Area / 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 SeuenCl U 11 i } C44 le I II?14 KA D LI r <br />PE <br />Code <br />LEACH LINES <br />❑ LEACHING CHAMBERS <br />Amount <br />Remitted <br /># OF LINES � <br />I <br />LENGTH OF LINES :!5.5 ft <br />Invoice # <br />Permit ID# <br />DISTANCE TO NEAREST <br />WELL <br />040 ft <br />FOUNDATION Lt <br />I <br />ft PROPERTY LINE ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO N REST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />U <br />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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - /jPLEASE CALL 209 953-7697 <br />SIGNED TITLE <a, , ✓4C1'Z'"- DATE lQ ' // _ "; / <br />��y� / DEPARTMENT US ONLY Q y, <br />Application Accepted By f G Date /� Area / 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 SeuenCl U 11 i } C44 le I II?14 KA D LI r <br />PE <br />Code <br />SC <br />INFO <br />Received Check#/ <br />By'L_Ciash <br />Amount <br />Remitted <br />at <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />L13� <br />11-7 <br />s b" <br />V111124 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />