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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />i4N JOAO— COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 46&3420 <br />NON-REFUNDABLE (P,'ERMIIT CALL 209 953-7697 FOR INSPECTIONS �.y, EXPIRES 1 YEAR FROM <br />/UATE ISSUEL <br />JOB ADDRESS O d S :'J " CITY/ZIP 1 r �V12N 1 DA-% gStp a ly <br />CROSS STREET TF"P'02 �.J'rbrJ R-� APN l - Z O O " 2- y PARCEL SIZE D •\4 4 /ICC <br />OWNER NAME CPC�OL-E r/#,JNJt LL- PHONE 44� ` " <br />OWNER ADDRESS 5 �^ -�Cw • CrrY/STATE/ZIP L-0-0 I ,_C A 44 Z <br />CONTRACTOR LIy E ms/� n"'� GEO El�I ✓I �N PHONE 3 5 - O 3 - <br />CONTRACTOR ADDRESS "'Tv W O'ocv- CITY/STATE%LIP I O -D I Crt 24 y <br />LICENSE ❑ f.X-42 ❑'LZ -36 OTHER C E Cr NUMBER ?-I S 1 EXPIRATION DATE ci - 30 Z <br />WATER TABLE DEPTH: <br />I D ` Z 0 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # <br />( BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />❑ NEW INSTALLATION ❑ <br />REPAIR/ADDITON <br />❑ ENGINEER DESIGNED/ALTERNATIVE <br />❑ REPLACEMENT 1*1 <br />OUT -OF -SERVICE SEPTIC <br />SYSTEM li DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE <br />❑ COMMERCIAL <br />❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ SEPTICTANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE To NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ UFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />❑ 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 ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED WIDTH ft LENGTH ft DEPTH It <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 />MIN/MUM/41 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209).953-7697 <br />SIGNED TITLE P�D_1 . m C- � . DATE ✓�' Zoo - �- I <br />Final Inspection By <br />Character of Soil to Depth of 3 Ft: <br />COMMENTS <br />Date ❑ SPECIAL PERMIT -Approved by <br />Pit/Sump Soil Character: <br />PE SC Received Chec Amount ate Permit/ Invoice # Permit ID# <br />Code INFO B Remitted Service Re est # <br />yaaa sa- M <br />44.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />