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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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS 1 10yy N• J0#JA ` CrrY2`1P 57D C-k7Zr^J 9T2-12-� p `� <br /> CROSS STREET �'1 I C-D�E�-� APN 017 S SO O" D, PARCEL SIZE I• T / d <br /> OWNERNAME t�}anrEST /-"DL&V/^j PHONE Z`1k- 3k-z3 <br /> /- C� rn <br /> OWNER ADDRESS r O p•C) �O� W J �Z CRY/STATE/Z1P 5rb�� CA ��2-� ` <br /> CONTRACTOR UV E O PCS Gnff-Ct_TlVIiec7%-,Me-A,)7&L PHONE 3&9 - C,3-75 <br /> CONTRACTOR ADDRESS 44 1 W O/914 S_ CITY/STATE21P Lor>( GA 9�El'qo <br /> LICENSE ❑C.IC-42 ❑❑C36 OTHER C E-G NUMBER :Z-I S I EXPIRATION DATE ')-Z Z <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: - Coordinates X Y <br /> PERC TEST # 1 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 CAPACnY 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 C! 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 /> ❑ DISPOSALPONDS 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 /> MINIMUM rt$HOUR AD ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED i TITLE Rle-4)j 6-0—• DATE y —3O- ZU <br /> I I <br /> t I I <br /> '1 <br /> I a \ <br /> — I <br /> T I I 202 <br /> Iil A, Q <br /> 1 O TUIVry <br /> 771 <br /> A( <br /> / / DEPARTMENT USE ONLY g k7' <br /> Application Accepted By ��- 1-L— Date a Area 9 I MCI Employee ID# L r`+ <br /> i <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 Received Check# Amount Permit/ <br /> Code INFO B as Remitted Date Service Request# Invoice# Permit ID# <br /> ya.9,0 sa3 p 1 2 1-Is2 2 0 <br /> 1 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />