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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 /> JOB ADDRESS 3 L S-1 ,pC,, PPC-14- L^J - c� CRY21P <br /> CROSS STREET G r vim' ` APN (, ` ,-4 D_ Oq PARCEL SIZE 2-'S 0 '4CC• b <br /> OWNER NAME EDDI c Vic C ot-wx 1 cx, PHONE 0 too) U-;L-08-`F- <br /> OWNER ADDRESS 2.S30 7CDoXv 4 L^-) CITY/STATE/LIP CTDGl-7--bJy Clq `rL0(p <br /> CONTRACTOR W%/E: O&W- 1 V I RtTNN't EN'i�CL PHONE 3toll-03115- <br /> CONTRACTOR <br /> 31S-CONTRACTOR ADDRESS 401 W, O Me- S"r' CITY/STATE/ZIP L0C>( C-4 0t 152-4 0 <br /> LICENSE ❑(..IC-42 0[JC-36 OTHER C'r+� NUMBER 2«( EXPIRATION DATE <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> X PERC TEST # J BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: U NEW INSTALLATION 0 REPAIRIADDITION D ENGINEER DESIGNED/ALTERNATIVE <br /> 1.1 REPLACEMENT 0 OUT-OF-SERVICE SEPTIC SYSTEM G 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 it FOUNDATION It PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES I':1 LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft 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 It 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 It <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <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 /> MINIMLLW8 UQUUM4ANCENOTICE RE IRED FRN 1 N -PLEASE CALL 209 953-769 <br /> 7 <br /> SIGNED TITLE 1712-0-1 ' e-tGoa' DATE <br /> It �MENECEIVE2021 <br /> JOAQUINCOUNTYVIRONMENTAL <br /> LTH DEPARTMENT <br /> lam[ <br /> / DEPARTMENT USE ONLY <br /> Application Accepted By l"�Gl Date 21112 Area �C Employee ID# AS <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 Receive Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO —Cash Remitted Service Request# <br /> ,).a sa3 T1s-c3i. <br /> 42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />