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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 />NUN-KthUNUAtSLt rI=HMl ly / UALL (LU.4) VOJ-/D`J/ hUK INSI-bUHUNS CXPIKES 1 TEAR FKUM UA IF ISSUEI <br />JOB ADDRESS �>�G7 oC l0 / ! /i /,�2-� %�/ %I/ai f-' ,J ��� CI <br />rTY/ZIP % J/IL L F� C/ ] �7 <br />CROSSSTREET //�//i l.Vl,(.1�I ii n/ APN //`(O/ 6 DD - Vy PARCEL SIZE <br />OWNER NAME :%2, Cil /' //t_u/1/t7 ff yvY PHONE <br />OWNER ADDRESS ,�/1 r11 II CITY/STATE/ZIP <br />�7 ] <br />CONTRACTOR ; ;t 1�.✓i C' r iyl -7 IS, C_ l L l UY1 (' -T C _ PHONE 4-� _I -- L/ / I"/ C . / —7 <br />7 5 <br />CONTRACTOR ADDRESS /,�F 1.3 CIN/STATE/ZIP <br />LICENSE 13❑C42 ❑❑C-36 OTHER 6,' NUMBER j` q Z `, � EXPIRATION DATE (p c <br />J <br />``11 I <br />WATER TABLE DEPTH: L I I J l ZV R GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED /ALTERNATIVE , <br />M REPLACEMENT 0 OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: R RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />A SEPTIC TANK TYPE/MFG ,(7 A- I^ C�':r'1 t'_J'Pi IL- CAPACITY 7 06,0 [gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPEIMFG ( CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELLR FOUNDATION R PROPERTY LINE R <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />Ll LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES It <br />DISTANCE TO NEAREST <br />WELL <br />R FOUNDATION <br />it PROPERTY LINE it <br />© FILTER BED <br />WIDTH tiU <br />ft <br />LENGTH <br />It DEPTH It°e 7G: fl <br />DISTANCE TO NEAREST <br />WELL <br />,?e <br />(OUNDATION / <br />it PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />R <br />nv <br />LENGTH �1V <br />/ <br />it DEPTH It <br />DISTANCE TO NEAREST <br />WELL <br />it FOUNDATION <br />it PROPERTY LINE it <br />❑ SUMPS <br />WIDTH <br />it <br />LENGTH <br />R DEPTH It <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />it PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH <br />R <br />LENGTH <br />R DEPTH it <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />It PROPERTY LINE it <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH it <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE R <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 />Final Inspection By Date ❑ SPEICIAL PERMIT -Approved by <br />Character of Soil .too Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS y f ou wetter U/V S!"7-cn- A <br />PE SC Received he Amount Date Permit/ Invoice # Permit ID# <br />Code INFO Cash Remitted Service Re uest# <br />o n u S Cj �5t�1 3 0 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />