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i <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA96205-(209)468-WO <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS IL6 W. AA(,k10N1; ILD CITYILP STOCKT N IS2.1S � <br /> CROSS STREET COPPIku)POLIS ILD APIN IU3�-Zoo-�$ PARCEL SIZEq-5 g <br /> OWNER NAME Ro btr+ •y M^J�a. A'I A1nO PHONE <br /> (?QIIJ �1�/61—,7S( <br /> �I 1�,7S(y <br /> OWNERADDRESS P.y, GO)(11 1 }� CITY/STATE0P pLTKIDJ &I (A. `5Z <br /> CONTRACTOR �-mok, r r�II.'V Omy { PHONE (7060 33I-41— 6n13��+jI <br /> CONTRACTOR ADDRESS Vq) N. CLVFF AV`, CITY/STATE/LP L00114 CA, SNO <br /> LICENSE .. C-42 C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAWADDITION ENGINEER DESIGNED IALTERNATNE <br /> REPLACEMENT OUT-OFSERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES U LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER Wore ft DEPTH ft <br /> DISTANCE TO NEAREST WELL 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 REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 48 HQUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> / p <br /> SIGNED TITLE S to F F DATE <br /> YIIAENT <br /> cEIVE® <br /> NVIRONMENTA TM <br /> LTH DEPARTMENT <br /> DEPARTMENT USE ON <br /> Application Accepted B Date �� Area ployee ID# Y` <br /> Final Inspectlon By Date ❑ SP AL PERMIT-Approved by <br /> Character of Soil t Depth of 3 Ft: PIt/Sump Sol�acter: <br /> COMMENTS PrC o0.�;D v1 ra Ll . 6 .oT%vtl,'rLc�i(U,4J <br /> PE SC Received Check#/ Amount to Permit/ Invoice# Permit ID# <br /> Code INFO C Remitted ervice Request# <br /> z > S 2d <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />