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7�JD Ir- kNrl"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 <br /> —¢� CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ��-t+! �� 1 V IQ"V w ECtUE+�-T H JT-CITY/ZIP T R- t'� c1 S�3OT <br /> CROSS STREET C f 1 r")S YY\t r rj APN f� I �I�I I PARCEL SIZE T-•1 q A< <br /> OWNER NAME K. (r(.1'✓1 E NT &(L CA.�p LLC PHONE(12- <br /> N <br /> OWNER ADDRESS 2<P VS CAVI 1)i-J0 -T PISS Ar2 f4 :I�I *,2.- CRY/STATE/ZIP bAij✓I L-Lr- C-r4 ITS 2..(.P <br /> CONTRACTOR LIVt ()ick- Ge01-NVIKor-f&I6gTkL- PHONE Z�9 3(a`t -037) <br /> CONTRACTOR ADDRESS &4 W Oft 1L Sj CITY/STATE/ZIP L0? L —A QS A"40 <br /> LICENSE ❑I IC-42 0110.96 OTHER a NUMBER 2(� L EXPIRATION DATE L'{' /O 17 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION D REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ 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 /> Aw e <br /> ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES �T <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ / <br /> FILTER BED WIDTH ft LENGTH ft DEPTH AI ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH It DEPTH SAAjft �2 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINEQ ft A <br /> ❑ SUMPS WIDTH ft LENGTH it DEPTHHztON yT� <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE piQTq A� I <br /> L3 DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH NT <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 /> MINIMUMR ADY4410E NOTI E REQUIRED FOR INSPECTIONS-PLEA E CALL 953-7697 <br /> SIGNED TITLE G R . DATE <br /> ey <br /> : <br /> I <br /> "Ay�.r a P Aj ,l <br /> yah u T 1 <br /> DEPA RTMENT US# ONLY <br /> Application Accepted By /� �� Date Area< Employee ID# 1 <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 Received Check Amount Permit/ <br /> Code INFO B ash Remitted Date rvice Re uest# Invoice# Permit ID# <br /> Baa sa3 - ls� <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />