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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT ` <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT //,�� CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS l go� L. Z�T1� S� CITY/ZIP .-A v <br /> H <br /> CROSS STREET • APN 17/- /7d-I ( PARCEL SIZE CJ `f -riC �' d <br /> OWNER NAME I-�\ �Lfj �� - PHONE <br /> y <br /> OWNERADDRESS rZ---L a% CITY/STATE/ZIPa—Ti1C,x-y"4 Dov--> f <br /> CONTRACTOR PHONE 4w6p bQS5 <br /> p 7 <br /> CONTRACTOR ADDRESS t Cl CITY/STATE/ZIP L <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPATR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ><-DESTRUCTION -it��<'1+ <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 /> ❑ PKG TX PLANT DISTANCE.TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING 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 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft kJw <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ 5UMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <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 <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE C 1,L(209)953-7697 <br /> SIGNED � L9 r TITLE � C � ...1A DATE 6-119-1 <br /> 11 0 <br /> IN 0 <br /> IR N E T L <br /> DEPARTMENT USF ON Y VjEALTH DEPA f <br /> Application Accepted B Date 5" 1 Area Employee ID# <br /> Final Inspection Ey Date S <9l ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Dept of 3 Ft: Pit/Surnifsoil Character: <br /> COMMENTS g�c c(G--II ct 01-F IU4_,<-f fir_ ( VrQ-, ea 12—ZV C(eC-�Pcr/ ������ f 1,Wee u',lrs_�41 �k <br /> PE SC Received ec Amount nate Permit/ Invoice# Permit ID# <br /> Code INFO By, Cash Remitted T Service Request# <br /> q2.2-( 0-7-5 <br /> 42-02-00ONSITE WASTEWATER PERMIT <br /> 12/221200 <br />