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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 ADA <br />((2 9) 953-7697 FOR INSPECTIONS tXPIRES 1 YEAR FROM DATE ISSUI <br />JOB ADDRESS / j ip 1 I & . ADA AVG CRY21,,Pww STD GA=f aN 9 s21 S <br />CROSS STREET SI5L F-14APN 103� 27V —00 6PARCEL SIZE 2-42—Ar- - <br />OWNER NAME JJ Atil RIJ(Z PHONE i2.3 -C>131 <br />OWNER ADDRESS S •7Wi C CITY/STATE/LIP I,, ` <br />CONTRACTOR LIVC ONIL &-�OF,QVIIZ/� ONMGN'-rip'L. rPHONE 3LP I G —0�1 J <br />CONTRACTOR ADDRESS 40 -7 LAJ . O &w- ST' CITY/STATE/ZIP Lo t> t C ON 7 p <br />S Zd4 0 <br />LICENSE a--' C-42 D' C36 OTHER CC&- NUMBER 7-15-1 EXPIRATION DATE 4-10-X2- <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ LEACH LINES <br />PERC TEST # <br />BUILDING PERMIT # <br /># OF LINES <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />_ NEW INSTALLATION <br />REPAIR/ADDITION <br />... ENGINEER DESIGNED/ALTERNATIVE <br />It FOUNDATION <br />REPLACEMENT <br />OUT -OF -SERVICE SEPTIC <br />SYSTEM I: DESTRUCTION <br />INSTALLATION WILL SERVE:_ RESIDENCE <br />J COMMERCIAL <br />a OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ <br />SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />LENGTH <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES It <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />It PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH It <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE It <br />❑ MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />It <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH It <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 COUNTY. <br />MINIMUM jWUR ADYAKE FOR INSPECTIONSE CALL (209) 953-7697 <br />SIGNED TITLE PQOJ • m 6-A • DATE y - 44 - 2-1 <br />DEPARTMENT US ONLY <br />Application Accepted B Z_�r�Z Date �3 Area L C Employee ID# <br />Final Inspection By s X Date ❑ SPECIAL PERMIT -Approved by <br />Character of Soil toDeptth of Ft: Pit/Sump Soil Character: <br />COMMENTS 0,S1 (Mi 4,/ 11^C/ <br />PE SC Received Check#/ Amount ate Permit/ Invoice # Permit ID# <br />Code INFO A 049 1 Ca Remitted Service Request # <br />I ,1�3 !s Z <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />Ty <br />