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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 ADDRESSC L' t CITY/ZIP Ue j <br />CROSS STREET C ` APN 13a so e a PARCEL SIZE L1 9 <br />OWNER NAME na }h R as ✓ n(� re, 3 Tld j 6, S PHONE <br />OWNER ADDRESS wM2 j CITY/STATE/ZIP <br />CONTRACTOR (404-e-0 F�pI l � PHONE 26 '3 Y `cl - 5502 <br />7 <br />CONTRACTOR ADDRESS 7 I .i•Y -1ee o 1V Dy CITY/STATE/ZIP <br />LICENSE ❑� 42 ❑❑C-36 OTHER NUMBER S 1 EXPIRATION DATE <br />WATER TABLE DEPTH: '1 nW'� �o ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # RP -910 O LAND USE APPLICATION # <br />TYPE OF WORK: I NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE <br />V REPLACEMENT } 6,11 J � IJ OUT -OF -SERVICE SEPTIC SYSTEM )( DESTRUCTION l VI17 K/ <br />INSTALLATION WILL SERVE: RESIDENCE <br />❑ COMMERCIAL ❑ OTHER <br />Received <br />B <br />NUMBER OF LIVING UNITS: / <br />NUMBER OF BEDROOMS: �� ) NUMBER OF EMPLOYEES: <br />Date <br />SEPTIC TANK TYPE/MFG G <br />L CAPACITY C2�00 gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />� i f <br />`/ w4b(J J C ft FOUNDATION fO ft PROPERTY LINE 5 ft <br />❑ <br />LIFT STATION SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />CHAMBERS <br /># OF LINES / LENGTH OF LINES 7V LJde ft <br />LEACH LINES ❑ LEACHING <br />/ <br />DISTANCE TO NEAREST WELL <br />/�L'(h1 C ft FOUNDATION ft PROPERTY LINE 5 ft <br />❑ <br />FILTER BED WIDTH ft <br />LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION(�C-Cl f ft PROPERTY LINE ft <br />❑ <br />MOUNDED WIDTH ft <br />LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />SUMPS WIDTH ft <br />), ft �0 <br />LENGTH ' �-DEPTH ft <br />/��/ <br />DISTANCE TO NEAREST WELL <br />U ft FOUNDATION [QC ' ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH ft <br />LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS NUMBER <br />WIDTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE loop, 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 />MINIMUM4�8�HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />a'✓ DATE -)' / — 12;t <br />SIGNED <br />�/ l�-�s� /!�� <br />TITLE @ el'- <br />DEPARTMENT U E ONLY (� n <br />Application Accepted By L— Date a / a a Area I % Employee ID# _ <br />Final Inspection By ?Wl Date Z-9' ZZ ❑ SPECIAL PERMIT - Approved by <br />Character of Soil to 6epth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS R )t-ceme f W'n d _ _ek5. /,Jto I,- c c ✓ / • ,' r <br />i•,1� ea�)j ay" l� �hd*,.r- p, pe, 6.f lf,.,th <br />��.nn.:,..�Ini� �� nn� �.nt,�f.•.i-{�✓ <riivin< Y1nW L.I X 11 X In reef <br />PESC <br />Code <br />INFO <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />Lia icy <br />Ips <br />2 X25 <br />3vz� <br />2Z <br />I o0 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />T <br />