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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> 1 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1pYEAR <br /> 2FROM DATE ISSUED <br /> t JOB ADDRESS 15�Q� •6 L�IV � ' <br /> � CITY21P <br /> CROSS STREET C/1 <br /> .}1-1S M A N APN ?'� 340PARCEL SIZE <br /> OWNER NAME vAAA L A-T K3A`" PHONE Z j O ` 0 <br /> 0.31 3 <br /> Vi <br /> •� Q h TIS t y <br /> OWNER ADDRESS 3 1 o I W . C-10iN c R-D. CITY/STATE/ZIP 2�V L� C A <br /> CONTRACTOR t-%%/E'�-do Ay— 6-C�0`/�`.JVV)XC#j X1'1E/VrA L PHONE .3111` 0315 �� <br /> CONTRACTOR ADDRESS ( w' 0 Aid- JT• CITYISTATE/ZIP L�D Grt 47(-ZA-AC) <br /> LICENSE -.C-42 _.0-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: LI NEW INSTALLATION i REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: L RESIDENCE I 1 COMMERCIAL J 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 It FOUNDATION ft PROPERTY LINE It <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES I LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE - ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 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 /> /MUM 24 ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 Q <br /> SIGNED TITLE tOINSVITANT DATE <br /> PAYMENT <br /> DECEIVED <br /> V t <br /> 0 JUN 18 2019 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> Lb LTH DEPARTMENT <br /> DEPARTME T U � <br /> Application Accepted y Date W R Area Employee ID# r C\ <br /> Final Inspection By Date 2 Cl $PECIA PERMIT-Approved by <br /> Character of Soil tooDepth of 3 Ft: Pit/Sump S it Character: <br /> COMMENTS PilfiC a f7b vi ra Q , - ki,Pt�t KGh <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Cas Remitted Service Request# <br /> 5 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />