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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-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 IO 1P S PA-TTE 12S6N PN- CITY/zIP <br /> :j <br /> CROSS STREET SffO APN Zo /'/o-v-Z-4 (Pr!An2 ) PARCEL SIZE 35-:A-c 4 (�` <br /> q 0 <br /> OWNER NAME -TC--r►+1y`c-H (iV r' PHONE `125`!ZAS0 ss 1 0 <br /> OWNER ADDRESS �' �a/� CITY/STATEIZIP C \PIT©LA CA <br /> CONTRACTOR U V E 'L0 A]IL Geo r-,tjyt eaje��AJT IPt L- PHONE ZO1I - 3(ay-0 p> r u <br /> CONTRACTOR ADDRESS 4 w" QAV— ST- CIN/STATE/ZIP <br /> LICENSE IC-42 -'.0-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> J-` PERC TEST #___J_ I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION - ENGINEER DESIGNED/ALTERNATIVE <br /> - REPLACEMENT 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 /> ❑ GREASETRAP 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 /> ❑ 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 It FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It 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 /> I M 15OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 q <br /> SIGNED /`<�� TITLE C-OAJh/t-i PC7�T DATE f` Z'- � I <br /> RFc k��lT <br /> JAN <br /> /,/04 <br /> o 0? ?af9 <br /> t//RO UlN co <br /> S l <br /> PARTMENT USE ONLY J } [ p <br /> Application Accepted By G Date L q Area Employee ID# <br /> Final Inspection By Date l SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: V Pit/Sump Soil Character: <br /> COMMENTS fC Vir.� tWpw> 66:ldkr 1y'e, H:.q jl'f� t� <br /> PESC Received Check Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Remitted Service Re ues <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />