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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) <br />209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE( <br />JOB ADDRESS I �D� WER•-r /zA -CITY/ZIP- L/'f�• <br />fil •o p 93' 3 3 D <br />CROSS STREET _T- -57 APN? <br />I I I JII4 PARCEL SIZE� (O• ryc. <br />OWNER NAME_ GI GT•L! C O PHONE((ZC 5) 2 q3 r - (' ZZ9 <br />OWNER ADDRESS C/O MGR EIIJ&IN EEP4 NG-' rZ`f 2- DVPO M' CITY/STATE/ZIP Alhoy—EGA CA '1533(p <br />CONTRACTOR I^ I VC O ek G" DjVIIeON/ijEj%_rI'n• L• PHONE 3 Cv9 - o 31 � <br />CONTRACTOR ADDRESS 4o -i W • C^AL� ST• CITY/STATE/LIP LODI (-'A/a <br />S2.44O <br />LICENSE ❑(..IC -42 00C-36 OTHER `y61 NUMBER ZI T' I30-2.2- <br />EXPIRATION DATE ``,, T - •� <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X y <br />PERC TEST # ( BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: ❑ NEW INSTALLATION L) <br />REPAIR/ADDMON ❑ ENGINEER DESIGNED/ALTERNATIVE <br />I.J REPLACEMENT fJ <br />OUT -OF -SERVICE SEPTIC SYSTEM I:J DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE <br />❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ <br />SEPTIC TANK TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />I DISTANCE TO NEAREST: WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />LIFT STATION SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES ] LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />FILTER BED WIDTH ft LENGTH <br />ft DEPTH <br />DISTANCE TO NEAREST WELL <br />ft <br />ft FOUNDATION ft PROPERTY LINE It <br />❑ <br />MOUNDED WIDTH ft LENGTH <br />ft DEPTH It <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SUMPS WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH <br />DISTANCE TO NEAREST WELL <br />ft <br />ft FOUNDATION ft PROPERTY LINE It <br />❑ <br />SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH <br />DISTANCE TO NEAREST WELL <br />ft <br />ft FOUNDATION ft PROPERTY LINE ft <br />I HEREBY <br />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 J8 HOUR ADVANCE NOTICE REQUIRED FOE INSPECTIONS - PLEASE ALL 20 953-769 7 <br />SIGNED zy2deAl k5f' <br />TITLE PIZOJ • DATE 8' Z I <br />PAYMENT <br />RECEIVED <br />AUG 2 3 2021 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />�—•�-� u C Y AHI MtN I US t ONLY <br />Application Accepted By L [s Date 7 l%I ; Area C Employee ID# _ <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 Permit/ <br />Code INFO Cash Remitted Dat Service Re uest # Invoice # Permit ID# <br />I S ? 1st <br />42-01 <br />4/14/18 - ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />