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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 GALL ZU9 <br />953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUE <br />JOB ADDRESS <br />r^ UU- 1/ n f <br />p <br />CITY/ZIP Imo('pQyl <br />/ j ,--33(O <br />CROSS STREET <br />ck✓1 toJ a Vop - <br />APN 12,74-110-15- <br />[ <br />PARCELSIZE I�1 v� <br />OWNER NAME C 'ock c <br />131 <br />lsa3 2 <br />PHONE 2,09 &Q 1 -7 <br />OWNER ADDRESS <br />2-000 Ti �r� %�_ rc <br />CITY/STATE/ZIP vy �l.W(�� co, L A- � � 33 <br />CONTRACTOR <br />' I <br />((—f�1 V l "D /I iey i Jw l I ['A <br />PHONE -J-0q <br />1 � Q <br />)- (' 0(' <br />CONTRACTOR ADDRESS <br />`t" `'r"(QQ 3 14,,v 9(i <br />1 <br />I ��'Z` �t rJ CITY/STATE/ZIP <br />✓1 UCS K- �On . CA- <br />LICENSE ❑I C-42 ❑ C-36 OTHER C- NUMBER al EXPIRATION DATE 10/911(0 <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIRIADDITION ENGINEER DE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM X DESTRUCTION <br />Y <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />TERNATIVE <br />❑ SEPTIC TANK <br />TYPE/MFG <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted Date <br />CAPACITY <br />Invoice # <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />lsa3 2 <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />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 />Application Accepted <br />Final Inspection By-dCharacter of Soil to D <br />COMMENTS St <br />DATE <br />/JC V /V L 1 <br />7 ,?.2 Area J ^i OkI Employee ID# <br />❑ SPECIAL PERMIT - Approved by <br />Pit/Sump Soil Character: <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />�a <br />ods <br />lsa3 2 <br />)K' l�lig C -c7�j <br />42-01 Cg l : ��� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 lJ 1 <br />T <br />