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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-REFUNDABLE PERMIT GALL 2U9 953-7697 FOR INSPECTIONS t_XPIRES I YEAH HHUM LJAIt ISSUEI <br />JOB ADDRESS SEC U;: SSC P1 LDS _ t3ELLOTrt -t' EL VYX CITY/ZIP �/C�vvl I nJG-rt C� nl I S 2 3 a <br />CROSS STREET S-7 T APN ' 2-0 --2- tP } —71 PARCEL SIZE Ci'S � At <br />OWNER NAME GLDP-I,* COIL­ LE- J PHONE `,1Ia) 4&-1 _2-S7-7 <br />OWNER ADDRESS 'T �- Z O 5. t� SC M -0-J - 13 E L(_ -DTA CITY/STATE/ZIP FM-,2',vk I N (�-T6T�% CA <br />CONTRACTOR Lt \.) O NK Cr L.yE�1 J l20 w� �„rVT,°2 PHONE 3(" `I - 031 <br />CONTRACTOR ADDRESS 4o -i w' O �� s T - CITY/STATE/ZIP L- O7 L C"A, I C1 i2-/ b <br />LICENSE ❑FIC -42 00C-36 OTHER L U� NUMBER L 1 � l'EXPIRATION DATE 4 -30 _ Z T <br />WATER TABLE DEPTH: <br />It GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />PERC TEST # <br />( BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />❑ NEW INSTALLATION II <br />REPAIR/ADDITION <br />❑ ENGINEER DESIGNED/ALTERNATIVE <br />WIDTH <br />❑ REPLACEMENT II <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />f 1 DESTRUCTION <br />INSTALLATION WILL <br />SERVE: ❑ RESIDENCE <br />❑ COMMERCIAL <br />❑ 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 />❑ GREASETRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />DISTANCE TO NEAREST: WELL <br />It FOUNDATION <br />It PROPERTY LINE fl <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 <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE It <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft DEPTH It <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />It LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE It <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft LENGTH <br />ft DEPTH It <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />ft PROPERTY LINE It <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />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 481H9UR <br />ADVANCE NOTICE <br />REQUIRED <br />FOR INSPECTIONS <br />- PLEASE CALL 209) 953-7697 <br />< <br />P2 �-) - <br />Cr2_' DATE <br />SIGNED <br />TITLE <br />ISI �C <br />C V-\�r-�, <br />SEP 14 2L92. <br />0 <br />IRONME=NTAL HEALTI <br />G^ ERMIT/SERVICES <br />G PAYMENT <br />s }3 iQ�. ��'� RECEIVED <br />s SEP 1 2022 <br />rr. �%. .<JOAQUIN <br />ENVIRONMENTAL AL <br />TH DEPARTMENT <br />%J <br />DEPARTMENT,USE ONLY q/ n%� <br />Application Accepted By `' L,L— Date <7 �� Area % Employee ID# �-+1 <br />Final Inspection By Date ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS _ <br />PE SC Receive Check#/ Amount Permit/ <br />Code INFO ash Remitted Dat Service Request # Invoice # Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />