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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT r GALL 2179 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE <br />JOB ADDRESS 35-0S- �E+ E. /C /� &tfT WILE XD . CITY2IP f��{, 7> f 9 S )-4 a <br />CROSS STREET /M IpC• KE Gftov c APN 0" " L �O r �+' PPARCEL SIIZZE7 4 kf Ac <br />OWNER NAME GV l- PA -6 ET J U •D0 G PHONE t-11 (. r OT - d Z1 ] <br />OWNER ADDRESS S f -Ir WA C CITY/STATE/ZIP p -7 -1 <br />CONTRACTOR LINE" {� L� �L+�%E N�)�N� E^T`� L PHONE 310 1 - 177 1 T p <br />CONTRACTOR ADDRESS `0-1 w • O &/K,, ST CITY/STATFJZIP I -O4-30-2,4 /b ( C -A %- Z -4O <br />LICENSE El: C-42 LI'.::7C-36 OTHER C c v NUMBER 2451 EXPIRATION DATE 4 -3 0 - ZT <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ LEACH LINES <br />Application <br />PERC TEST # I BUILDING PERMIT # <br /># OF LINES LENGTH OF LINES ft <br />LAND USE APPLICATION # Ph-kl-7 O ;-4I <br />TYPE OF WORK: NEW INSTALLATION <br />REPAIR/ADDITION <br />._, ENGINEER DESIGNED/ALTERNATIVE <br />❑ FILTER BED <br />REPLACEMENT _ <br />OUT -OF -SERVICE SEPTIC <br />SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: CI RESIDENCE <br />J COMMERCIAL <br />L OTHER <br />ft FOUNDATION ft PROPERTY LINE ft <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ <br />SEPTIC TANK TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />ft LENGTH <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />LIFT STATION SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />Application <br />LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES ft <br />Permit/ Invoice# PermitID# <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft DEPTH R <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />It DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft DEPTH ftI <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH It <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE It <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STATE LAWS AND RULES AND <br />REGULATIONS OF SAN JOAQUIN COUNTY. <br />M/ <br />E <br />NOTICE REQUIRED <br />FOR INSPECTIONS- PLEASE -7 7 <br />Op ���� <br />toR-0 2 <br />Y" C -A • DATE I - 19' "22- <br />SIGNED <br />TITLE • <br />Application Accepted B Cr <br />r <br />Final Inspection B L f I " <br />Character of Soil topth o�f�3 �Ft: _ <br />COMMENTS c t t tJ /) l i `„ <br />DEPARTMENT USF ONLY ,J <br />Date0 Area <br />Date ❑ SPECIAL PERMIT <br />Pit/Sump Soil Character: <br />1 yv <br />Employee ID# f c1 N k <br />Approved by <br />PE <br />SC Received Check # <br />Amount Dat <br />Permit/ Invoice# PermitID# <br />Code <br />INFO B <br />Remitted <br />Service Re uest # <br />2-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />� <br />T <br />/ryCONP.4�0N7,��N <br />