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A <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 4883420 <br />NON-KEFUNDABLE PERMIT GALL LU'J 9bJ-7697 FOR INSPECTIONS tXPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS I I (pis Z N • HAM L.IV • CRY/ZIP L 91".% 1 <br />CROSSSTREET J w e sT LN APN 0S-97 - ZS -0 - 073 PARCEL SIZE Ii,' 144 • <br />OWNERNAME CIO 6hrty WFW_r, E,NV)tWNW11t IV1 PcL EN'S=PRISES PHONEMS-I/ 212-130 <br />OWNER ADDRESS -) I C th G 0 (a1 0n • CITY/STATE/ZIP C ft I C O ,, CA 191-41 2.,rr <br />CONTRACTOR•IVC 014�IC Geo E&)J(1Z4" F_AJTAr L PHONE 3(o? - ol-I J <br />CONTRACTOR ADDRESS 40 _I W ' O IMK- S T • CRY/STATE/ZIP l,oD ( CA Cly" -L40 <br />LICENSE ❑EIC -42 OCC -36 OTHER cc C: NUMBER '2' I'V I EXPIRATION DATE q -:?o - 2 Z <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />iK PERC TEST # <br />I BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />.... NEW INSTALLATION [: <br />REPAIR/ADDITIONI:; <br />ENGINEER DESIGNED/ALTERNATIVE <br />.... REPLACEMENT _ <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />I) DESTRUCTION <br />INSTALLATION WILL <br />SERVE: ❑ RESIDENCE <br />❑ COMMERCIAL <br />11 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 />TYPEIMFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE <br />DISTANCETO 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 />LEACHING CHAMBERS <br />Amount <br />Remitted <br /># of LINES <br />y3aa <br />LENGTH OF LINES <br />ft <br />•� •Z2 S g � <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ FILTER BED <br />WIDTH <br />It <br />LENGTH <br />ft <br />DEPTH <br />f8, <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />ft PROPERTY LINE <br />T/t1�7 <br />❑ MOUNDED <br />WIDTH <br />It <br />LENGTH <br />ft <br />DEPTH <br />aS:GA,f <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />ft PROPERTY LINE <br />❑ SUMPS <br />WIDTH <br />It <br />LENGTH <br />It <br />DEPTH <br />t,Q/ <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />It PROPERTY LINE <br />❑ DISPOSAL PONDS WIDTH <br />It <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />ft PROPERTY LINE <br />fl <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />ft PROPERTY LINE <br />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 AWUR ADVAKE NOTICE RE IRED FOR INSPECTIONS - PLEASE CALL (2 09) 953-7697 <br />SIGNEDTITLE I�aoJ •6%L ' DATE <br />DEPARTMENT USE ONLY !� <br />Application Accepted By !� L_ Date Z Area 4 I Employee ID# <br />Final Inspection By e3=-� _ j(O1niG'L Date 2222 _ ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS <br />PE <br />Code <br />SC Received Check # <br />INFO <br />Amount <br />Remitted <br />Date Permit/ Invoice # Permit ID# <br />Service Request # <br />y3aa <br />sa3 <br />)s a <br />•� •Z2 S g � <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />16 ';0 " <br />/N <br />NFNOUNlY <br />9RrAt <br />�FNT <br />