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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 />JOB ADDRESS <br />L_C-p <br />tXPIRES 1 <br />CROSS STREET ' 1 (( 313A-�J APN 00 - Z�i� -O � �PjARCEL SIZE 3-12- A. <br />OWNERNAME Ozt1313� �%�!�`-j�Z PHONE 1-%Ol - 61k <br />OWNER ADDRESS/ S �nq�.� /' �}, c� �--�q CrrY/STATEJZIP <br />CONTRACTOR LAI%E ©P �K- C --67b EDI V1 P. 0/yrnC " I V L PHONE 3�'�l <br />CONTRACTOR ADDRESS L40-7 w- CA -v- -� ` • �7 CRY/STATE21P "4-30-2-2- <br />WATER <br />r <br />LICENSE ❑0042 ❑l7C-36 OTHER C�-G% NUMBER ZI5J ( EXPIRATION DATE T-30_2-2 <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />TK PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: D NEW INSTALLATION 0 REPAIR/ADDrnON 0 ENGINEER DESIGNED/ALTERNATIVE <br />Ii REPLACEMENT I OUT -OF -SERVICE SEPTIC SYSTEM 0 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 ft FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES I LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES ft <br />ION <br />ft PROPERTY LINE <br />DISTANCE TO NEAREST <br />WELL <br />Yff� <br />ft FOUNDAT <br />FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />ft PROPERTY LINE <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />SUMPS <br />WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ION <br />ft PROPERTY LINE <br />ft DEPTH <br />Yff� <br />ft PROPERTY LINE <br />ft <br />ft DEPTH <br />ft PROPERTY LINE <br />ft DEPTH <br />ft PROPERTY LINE <br />ft DEPTH <br />ft PROPERTY LINE <br />It <br />_ft DEPTH <br />ft <br />ft PROPERTY LINE <br />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 />MINIMUM 42 UOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 953-7697 <br />SIGNED TITLE DATE 1 -3—Z -72 -- <br />COMMENTS `3_ZZ <br />COMMENTS <br />PE SC Received ec Amount Date Permit/ Invoice # Permit ID# <br />Code INFO By sh Remitted Service Request # <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />