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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 r CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I R 3S A • TSS--T. /Z-f.. q W- 'moi T4r. crrY21P A-C awl Pa 9S'yZ-D ti <br /> CROSS STR EET L D 0>1 z,ry/�'st APN 0r 3-1-2-D.D -3 Z PARCEL SIZE •37 <br /> R0 <br /> OWNERNAME fJrrD Cti-Rl S • J��,J PHONE 337 -53 `-3 <br /> OWNER ADDRESS P.,0. P3b)( I'Z I CITY/STATEIZIP ►yo'C'D132/3>G£ CA q5' SC <br /> t-IVE DSK GEO�NVITeOnJ�E �tL PHONE 3109- 03-75 <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS <br /> Z'V-1 Qfk lG �i I CRY/STATE/ZIP <br /> LICENSE 0I..IC-42 ❑DC36 OTHER CGC7- NUMBER �'lSI ExPIRATION DATE -� a- 2Z- <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: 0 NEW INSTALLATION 11REPAIR/ADDRION D ENGINEER DESIGNED/ALTERNATIVE <br /> D REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM C; DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal *OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ElPKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES 0 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 WELLft 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 PROPERTYLINE It <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELLft FOUNDATION ft PROPERTY UNE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELLft FOUNDATION ft PROPERTY UNE R <br /> 1 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 4UR ADYAWE NOTICE REQUIRED FOR INSPECTIONS-PLEA E CALL(209)953-7697 <br /> SIGNED TITLE P/-0`- I>tiV�• DATE <br /> m <br /> INV <br /> ?02� <br /> JJ / DEPARTMENT USE ONLY G H� FNT�H� <br /> Application Accepted By ��� yL Date /aI Area q / Employee ID# •r <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved t V ANT <br /> Character of Soil to Depth of 3 Ft: PiVSump Soil Character: <br /> COMMENTS <br /> PE SC Received BehAmount Date Permit/ Invoice# Permit ID# <br /> Code INFO B as Remitted Service Request# <br /> a la s'13 0 ¢iso 9•21 51C <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />