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T" ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-FIh1-UNUACLE YEHMII LALL ZVY W041 -/0J/ 1 -UH I1Vb4-6GI1U1VS CEYIHtS I TtAH t -HUM UAIh IS5Utl <br />JOBADDRESS Sac °F ESCALow-3ELL.oTt t" ELVVA CITY/ZIP TN1Z-mIA 0-tj-)/'i IS 23�l <br />CROSS STREET S- ' 12- T ' y APIN ' - I Z17 1P '3' - 2-1 PARCEL SIZE (] 'S I Ar. <br />OWNERNAME 6L-ORGIA' GAJ L-I_IZ1,J <br />OWNER ADDRESS L4 a 2 0 S' tSc A I'UrJ - 13ELA-vT A <br />CONTRACTOR L.t v t 0k\4- <br />G �-vEN J 120 a vti1 �,rvr tet, <br />CONTRACTOR ADDRESS -4O, w' O AIZ' s -r' <br />PHONE `-i(}J L461 -1S2-) <br />r <br />CITY/STATE/ZIP C4ivo'vv\ IN C -TD -PJ C A 91 r 7-3 6 <br />PHONE -3 1 - 01, <br />CITY/STATE/ZIP L- Ob l < .A q S -2.g6 <br />LICENSE '- C-42 Ll C$G OTHER C 0 6- NUMBER L 1 �- 1 EXPIRATION DATE -4-30-L-4 <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ LEACH LINES <br />PERC TEST # <br />C BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />NEW INSTALLATION <br />REPAIR/ADDITION <br />ENGINEER DESIGNED/ALTERNATIVE <br />ft LENGTH <br />It DEPTH ft <br />REPLACEMENT -... <br />OUT -OF -SERVICE SEPTIC SYSTEM _ DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE <br />G COMMERCIAL <br />- OTHER <br />WIDTH <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ <br />SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />WELL <br />it FOUNDATION ft PROPERTY LINE It <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />I LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES ft <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />It DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />It DEPTH It <br />DISTANCE TO NEAREST <br />WELL <br />it FOUNDATION ft PROPERTY LINE It <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION ft PROPERTY LINE It <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH It <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION 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 <br />REGULATIONS OF SAN JOAQUIN COUNTY. <br />MINIMUM 48,fH9UR <br />AF VAMCE NOTICE <br />RE <br />IRED FOR INSPECTIONS - PLEASE CALL 209) 953-7697 <br />SIGNED <br />TITLE PR'DJ' l�l��-' DATE <br />% DEPARTMENT US g ONLY �•� ��`�� <br />Application Accepted By ' " �" Date �� Lf Area ! Employee ID# <br />Final Inspection BYE Date 2 `J �Q l2 �1-�ECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS ���p i Q-� PAbS (_`-1 '�6N/\ <br />-NA Q, „Q P T R��� C94z) -4--, r-.a�\ <br />PE SC Receive Check#/ Amount Dat Permitt Invoice # Permit ID# <br />Code INFO ash Remitted Service Request # <br />CF 11{C <br />sc? 14 2022 <br />IRONMENTAL HEALTH <br />DERMIT/SERVICES <br />PAYMENT <br />RECEIVED <br />SEP 14 2022 <br />n JOAQUIN COUNTY <br />ENVIRONMENTAL <br />+4LTH DEPARTMENT <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />