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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 VERMIT <br />903-/ti,91 FOR INSPECTIONS <br />1 YEAR FROM DATE ISSUEI <br />JOBADDRESS Zy�Z <br />jjL;ALL/LUY <br />i� j✓� �-0- <br />CITY/ZIP �'(�/"K,4Jl+ <br />//EXPIRES <br />CROSS STREETI <br />APN / <br />�� ��L� - l �S <br />PARCEL SIZE <br />jj <br />OWNER NAME D5 �S'�/ <br />< /".4 a 1M 1 ILS `—P <br />LIFT STATION <br />� <br />PHONE / 6 2 2 <br />�GI <br />LEACH LINES <br />❑ LEACHING CHAMBERS <br />OWNER ADDRESS �n� <br />CITY/STATE/ZIP <br />DISTANCE TO NEAREST WELL '��': ft <br />/�� <br />CONTRACTOR /%�`/A�/�(//� <br />n l <br />l\P1 1 C fJ �ei s✓ <br />PHONE �i�J <br />C <br />CONTRACTOR ADDRESS / -/ L1 <br />�P�N e J .%/• <br />CITY/STATE/ZIP <br />/�/%�/ /7J <br />'I �o'� v /' <br />LICENSE ❑❑C-42 110C-36 OTHER NUMBER I �, <br />c <br />r J� EXPIRATION DATE <br />MOUNDED <br />WIDTH ft LENGTH <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: ❑ NEW INSTALLATION `$ REPAIR/ADDITION ❑ ENGINEER DESK <br />❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL sepIt, ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: q pL YYN I f -/��1I a7-3 -5'D NUMBER OF EMPLOYEES: <br />TERNATIVE <br />❑ <br />SEPTIC TANK <br />TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP <br />TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES <br />❑ LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES �a ft <br />DISTANCE TO NEAREST WELL '��': ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />FILTER BED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS <br />WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />Ir <br />SEEPAGE PITS <br />NUMBER 11- _ WIDTH <br />'-! tJ ft DEPTH 2 j ` ft <br />DISTANCE TO NEAREST WELL�ft <br />FOUNDATION Zv 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 <br />HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED <br />_ <br />�� <br />TITLE DATE <br />DEPARTMENT,JJSE ONLY <br />Application Accepted By— / Date Area >• Employee ID# <br />Final Inspection By Date Z `Z ❑ SPECIAL PERMIT - Approved by <br />Character of Soil to De th of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS Nni^ tP o,lr ler QeX1sf�n "96 -Id l,C, s li7d(ldlr7/i <br />�J( I'1B'� YOGt!�. chi//h� nN✓l i1�P orS- <br />PE SC <br />Code INFO <br />Received Amount <br />B Cash Remitted <br />Date Permit/ Invoice # <br />rvice Re est # <br />Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />