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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-KEFUNDABLE/PERMIT r GALL ZU9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE. <br />JOB ADDRESS / 7 0 U 'L7L� i ` �( CITY/ZIP C d % �3 <br />CROSS STREET ��11, � �Li Y( Com! R (-� APN V 0 3 U o s ' PARCEL SIZE <br />OWNER NAME <br />n til r Q_s <br />PHONE <br />Amount <br />Remitted <br />OWNER ADDRESS Pr O L <br />J <br />� / � J J CITYISTATE/ZIP %I�L n It <br />G <br />CONTRACTOR le,?A e - <br />4 <br />` l <br />PHONEy/J�� <br />#300 <br />CONTRACTOR ADDRESS / <br />pts` %� <br />y `^ ` J � <br />CITY/STATE/ZIP —� -1/G <br />7 J J -J <br />LICENSE ❑DC -42 ❑QC -36 OTHER <br />/ <br />NUMBER �r ) �J <br />EXPIRATION DATE A/ <br />ZA <br />J -, ', _2y e <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: I I NEW INSTALLATION REPAIR/ADDITION El ENGINEER DESIGNED /ALTERNATIVE <br />C1 REPLACEMENT / I � OUT -OF -SERVICE SEPTIC SYSTEM F1 DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL E OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />❑ GREASE TRAP <br />TYPE/MFG <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />❑ LIFT STATION SIZE TYPE OF PUMP <br />CAPACITY <br />CAPACITY <br />ft FOUNDATION <br />❑ 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 1 1 LEACHING CHAMBERS # OF LINES <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />43 FILTER BED WIDTH /J ft LENGTH -? (r, ft <br />DISTANCE TO NEAREST WELL S U ft FOUNDATION -z- <br />[3 <br />❑ MOUNDED WIDTH ft LENGTH ft <br />DISTANCE TO NEAREST WELL <br />❑ SUMPS WIDTH ft LENGTH <br />DISTANCE TO NEAREST WELL <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />DISTANCE TO NEAREST WELL <br />❑ SEEPAGE PITS NUMBER WIDTH _ <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft <br />ft FOUNDATION <br />ft <br />ft FOUNDATION <br />ft <br />ft FOUNDATION <br />LENGTH OF LINES ft <br />ft PROPERTY LINE !, ft <br />DEPTH /,1), '-5 �C �[��t' ft <br />ft PROPERTY LINE S ft <br />DEPTH ft <br />ft PROPERTY LINE ft <br />DEPTH ft <br />ft PROPERTY LINE ft <br />DEPTH ft <br />ft PROPERTY LINE ft <br />DEPTH ft <br />ft PROPERTY LINE ft <br />1 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 />SIGNED <br />DATE <br />Final Inspection Byff'ktgnDate 2.� r/!✓ 7OLZ ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS IJon 104- ), 7 fer r , I'n �eDte11,eroen � bf Lecich ()e ld 1' Xlf.sfrhG �IY1PS tQ 6e '1%as n12 <br />taf ne"i M -0i, Diet rn f 67 1Pe<h (*,'P. Id' r arW� b7 PAj-!5 H h Cj'eW W ;�h <br />t <br />( Vim en t ►n/Cis <br />t tQ he- citign over dr <br />PE Sc <br />Code INFO <br />Received <br />By <br />eck# <br />sh <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # Permit ID# <br />�D )ls <br />3i2 <br />#300 <br />Z �� <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />T <br />