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Z � ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SANJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)46$-3420 <br /> 1 <br /> NON-REFU IT CAJL(209 953- 6 OR INSPECTION* j XPIRESI.YPAD rpnRAnATE ISSUED <br /> .los ADDRESS CITY/ZIP <br /> M <br /> CROSS STRE APN rn- PARCEL SIZE p <br /> r o <br /> PHONE <br /> OWNER NAME Ir 612 { �.7 M <br /> OWNER ADDRESS �" CITYISTAT32"n7 <br /> CONTRACTORr �• C PHONE <br /> CONTRACTOR ADDRESS ° '�/ CITYISTATEIZIP c)sw5 <br /> LICENSE A-42 QC-36 OTHER A NUMBER + EXPIRATION DATE <br /> I <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# 00 (,L LAND USE APPLICATION# <br /> TYPE OF WORK: 0 NEW INSTALLATION 17REPAIRIADDITION ENGINEER DESIGNED(ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERC AL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF EDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPEIMFGFlL CAPACITY gal #OF COMPARTMENT$ <br /> I GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE a.l� tt <br /> ❑ LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT AND OIL SEPARATOR(ENCL-OS1E6 SYSTEM) <br /> W LEACH LINES YLEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft N <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> © SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ^ i <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft 1� <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft I� <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 /> MI IM N ICE REQUIRED FOR INS?A' <br /> PL 5 09]953-7697 �j <br /> SIGNED , TITLE DATE7—`� <br /> I <br /> 5;7A 464 <br /> IL <br /> -71 <br /> P <br /> -71 166> <br /> �. <br /> 74, <br /> -�_ <br /> N IR N E TA <br /> rMAL E M <br /> 1 <br /> LLr; <br /> DEPARTMENT USF ONLY <br /> Application Accepte�t y +- -� Date f� Area Employee ID# 37 q o�q <br /> Final Inspection B1 Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to D pth of 3 Ft: P tlSump Soil Character: <br /> COMMENTS OL..6 "-r--OF ,�IEc_o � 2 �t7 cC t.��,�.�6-ra�4;�G�c_S �rc�ucuJg-Lcr <br /> -cC o J S 1 I ` - S <br /> PE SC Re eived Chec Amo nt <br /> Code INFO ash Remitted Date �j Service Re uest# Invoice# Permit ID# <br /> 42-31 5'3 <br /> 42-01 ✓ ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 1014!07 <br />