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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 �CAL�L(209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 3131 O 4-31 -51k >•`' 7 33 CIT-Y7/ZIP 1 �f�G q r3{yf' <br /> L <br /> J k �/{•� y <br /> CROSS STREET ' t APN ZS )�% Z� PARCEL SIZE �'t"f"� " ` p <br /> OWNER NAME r • -�L� w ` ` PHONE <br /> OWNER ADDRESS I (p ' CITY/STATE/ZIP <br /> CONTRACTOR L-)%-)F,7 O r°111Y (S�C•�?�3 I'2ciy��Eh.�l`VL- PHONE 3k,,--(- <br /> CONTRACTOR <br /> b,--(-CONTRACTOR ADDRESS 4�0 1 W• C -5—' CITY/STATE/ZIP `O-'�>• <br /> LICENSE ❑i iC-42 ❑:7C-36 OTHER C E NUMBER ZI�, ExPIRATION DATE `-•f_��-� ^Z�2 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: 7 NEW INSTALLATION ❑ REPAIR/ADOITION D ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM E 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 TYPEIMFG 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 It 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 ft 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 /> MINIMY&tgo 4OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TIME DATE <br /> Y-8-1�Nr <br /> V <br /> 022020 <br /> Application Accepted By � L <br /> DEPARTMENT Date C la U�J:i-D L Y O <br /> Area 5 �I Employee ID#'�""O/V Ady��' <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by AR7-mElvr <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received ec Amount Date Permit/ Invoice# PermitID# <br /> Code INFO By Cash Remitted Service Re uest# <br /> iia saz €lsa �' 41 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />