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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-HEFUNDABLE PERMIT GALL (ZU'J) YbJ-1bY1 FOR INSPECT/ONS EXPIRES 1 YEAR FROM DATE ISSUI <br />JOB ADDRESS237J102 NT AJ. (31=Ut-LL-A (L -b CITY/zIP /fr_ A• wt,Pz) c .iz--O G ^ - <br />CROSS STREET ?J"t A A� APIN OO - ��f-C7 - D I PARCEL SIZE /� -- Z (2 <br />T <br />OWNER NAME / (LACy GLf�F� PHONE -7 1 �✓� <br />OWNER ADDRESS S�•�"'IG -• I ��.+� 1 S 3� CITY/STATE/ZIP ✓,C� 1; <br />CONTRACTOR QVC- Oei1G GC(7EAJV1izz)eu YIEAJ7-A L PHONE 3(P!q'd3 1 7 5 <br />CONTRACTOR ADDRESS A10-7 lam% • D A14 S--' CITY/STATE/ZIP LOD ( C -A <br />LICENSE 11CIC42 00C-36 OTHER CE-cr NUMBER Z I S ( EXPIRATION DATE -� 0 - L Z <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />PERC TEST # <br />BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />❑ NEW INSTALLATION 0 <br />REPAIR/ADDITION <br />❑ ENGINEER DESIGNED/ALTERNATIVE <br />It DEPTH ft <br />❑ REPLACEMENT EI <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />1::1 DESTRUCTION <br />INSTALLATION WILL <br />SERVE: ❑ RESIDENCE <br />❑ COMMERCIAL <br />❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />f.:l LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH <br />It LENGTH <br />It DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE It <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft DEPTH It <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE it <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 <br />AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />MINIMUM 4MOUR <br />ADVANCE NOTWE <br />REQUIRED <br />FOR INSPECTIONS - PLEASE CALL 2953-769 <br />SIGNED46A4�TITLE <br />PQ -d • >M 6(Z • DATE 10 <br />/ DEPARTMENT SEONLY <br />Application Accepted By e G— Date / D / Area l (1 <br />Final Inspection By Date ❑ SPECIAL PERMIT <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS <br />YMENT <br />CEIVED <br />18 2021 <br />Employee ID#Fr'SAN�IOAQUIN COUNTY <br />_E"VIRONMENTAL <br />Approved by HEALTH DEPARTMENT <br />PE SC Received Check#/ Amount D to Permit/ Invoice # Permit ID# <br />Code INFO h Remitted Service Request # <br />L13919 5193 6K JL 1� SMY (PLI <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14118 <br />