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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697FOR INSPECTIONS . EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 211-1 s. C O�R1tL Ij-OLI,O�n.3 (ZD. Crrr21P 'I�kGy30`�' <br /> CROSS STREET <br /> C-t_oVE2 APN Z <br /> OWNER NAME I Z-fPp-OZ PARCEL SIZE t.66 'Ill5 o <br /> I� <br /> n r,r, 'D PHONE <br /> OWNER ADDRESS SSC I�CI I J'•1� SY{;�'r�- Dr Cm/STATE/ZIP �)!-r ✓ �C�77 - <br /> CONTRACTOR L.I J E U A— G Eo F�fz--pN m Ems,-TPC L- PHONE 3 e q-O32 S <br /> CONTRACTOR ADDRESS j,)• O A-1= ST . CITY/STATE/ZIP L-0>1 C-A JI S L-40 <br /> LICENSE "'::'C-42 ECC36 OTHER Gr'C7 NUMBER ZI 1 EXPIRATION DATE &4�3C-2.Z <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 ENGINcER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM - DESTRUCTION <br /> INSTALLATION WILL SERVE: a RESIDENCE 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 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 N EAREST 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 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 1 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 OUR A M44NCE NOTICE REQUIRED FOR INSPECTION -PLEASE CALL 209 251:769 <br /> SIGNED TITLE �26 ✓h G2. DATE Z C7 <br /> i <br /> I <br /> I <br /> I, 5 <br /> I <br /> I I ti I <br /> 22020 <br /> IE/yT��Y <br /> DEPARTMENT USE ONLYT� R TME/Vr <br /> Application Accepted By �-- Date o ' Area Gl Employee ID# o/{-t <br /> Final Inspection By Date G SPE AL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Chec Amount Permit/ <br /> Code INFO B ash Remitted Date Service Re est# Invoice# Permit ID# <br /> 1.1 sa I PSa ID12 121 <br /> 42.01 ONS-E WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />