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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 />NUN-HEFUNDABLLE PERMIT � <br />C CALL (209) 953-77697FOR INSPECTIONS EXPIRES 1jYEAR FROM DATE ISSUI <br />JOB ADDRESS A9•1'1 • E-SCAIiC^ MLA -C 1 & A RL -P • CITY21P kSC.^L-O Ijl 1 S 4D <br />CROSS STREET SKIFF APN_ 2-01-030-01 PARCEL SIZE 2• S AC <br />OWNER NAME FIT PIE *>w I S PHONE 1 (� ' I III— <br />OWNER <br />IOWNER ADDRESS -706 E. F/tl R m o rwr AV f. • CITY/STATE/ZIP w 0 ✓e STV CA 1 S 3 S'a <br />CONTRACTOR L_W6 o^w- &P--peN,/I94NW1e/y-rAL PHONE -11, 037 S' <br />CONTRACTOR ADDRESS d{y"I 11,4 • 04x- 571% CITY/STATE/ZIP (r01>t 9 j -2.•{a <br />LICENSE L_ - C-42 C-36 OTHER C e. G NUMBER 7-15 I EXPIRATION DATE 4-3o-2.2 <br />WATER TABLE DEPTH: If 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 />❑ SEPTIC TANK TYPEIMFG <br />❑ GREASETRAP TYPEIMFG <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 ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />. LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES ft <br />PE <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE If <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />Ll DL <br />ft DEPTH It <br />1ST <br />DISTANCE TO NEAREST <br />WELL <br />If FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />If LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />It PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />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 <br />COUNTY. <br />MINIMUM <br />R AQ CE NOTICE <br />RE <br />/ ED FOR WSPECTIONS <br />- PLEASE CALL (209) 953-769 <br />SIGNED <br />TITLE ioRZOJ • <br />�i1 bIQ DATE 1 3 - &-2-1 <br />DEPARTMENT S Ej ONLY t <br />Application Accepted By �— /� 1 �-- Date 2 O Area �% C/ Employee ID#��� <br />Final Inspection By Date ❑ SPECIAL PERMIT - Approved by <br />Character of Sail to Depth Ft: Pit/Sump Soil racier: <br />COMMENTS ' <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />PE <br />Sc Received Che / <br />Amount <br />Permit/ <br />Code <br />INFO B ash <br />Remitted <br />D to Invoice # PermitlD# <br />Service Requiem # <br />Ll DL <br />S�3 <br />1ST <br />C 21 $ 4G.9 3 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />