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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 e CALL(2009 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1033- 1 N/• �r—• 9-T -/It K)4 CITY21P 5-1 b�-✓�"Ta� v' <br /> �y� H <br /> CROSS STREET Wok LL�•r`� APN )2Z' 03:0 01* (Za <br /> PARCEL SIZE A-C • p <br /> OWNER NAME T G=fT61C& FP I,'i I010 JC,)7^ PHONE (041 ' �•ZS) <br /> � <br /> + c y <br /> OWNER ADDRESS a_ -7I Zi .L-OS d�"I�0 CT• —CITY/STATE/ZIP '1P 1�VLK-7TD -j f (A r Q! Z'1 o <br /> CONTRACTOR L-I V Cy IIp`k G't by v 1�J (Z>,�N Nn��TA L PHONE <br /> CONTRACTOR ADDRESS CITY/STATE21P <br /> LICENSE ..,,C-42 ❑-C-36 OTHER PU NUMBER !/VD 1 E%PIRATION DATE 1 13O' <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 REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE 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 LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft 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 ft <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 It PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH 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 /> ,a AVJ%NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL953-769 <br /> SIGNED TITLE Pao • � IG'fz • DATE <br /> yMFNT <br /> ��VFO <br /> � NC <br /> OV <br /> DEPARTMENT SE'ONLY <br /> Application AcceptedAy Date Area Employee ID# �TMFHT <br /> Final Inspection By Date 0 !7 SPECIAL PERMIT-Approved by <br /> Character of Soil to epth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS rerG —J- q ✓� <br /> PE SC Received heck Amount Date Permit/ Invoice# PermitID# <br /> Code INFO B sh Remitted Service RCquest# <br /> Llaaa s a3 8 Is td r <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />