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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET•STOCKTON CA 95202-(209)466.3420 <br /> NON-REFUNDABLE PERMIT CALL:c209 9533-7697 FOR INSPECTIONS EXPIRE <br /> S 11 YEARR+FROM DATE ISSUED <br /> JOB ADDRESS 53/D LA-& ?os(-T� ) C I�++ CITV21P ��ilL��y %S ZIz y <br /> CROSS STREET o! \�(�'I L�t APN D�� -D PARCEL SIZE <br /> OWNER NAME mttNJ nit r� /J�th�/►�tt-�'�,� ���,�(, (' { wBNE �� �AgSZ y <br /> OWNER ADDRESS /}S fl Y✓1 16�FSo C. /TDI�7f��-� CITY/STATEIZIP WC- CA <br /> CONTRACTOR U V 1� ((U PI L Gf V E NV J(Lp fV M F-W I YAl— PHONE <br /> — <br /> CONTRACTOR 3C9`1-0 3 A <br /> CONTRACTOR ADDRESS D-9 o' 0 1� S"` CITY/STATEIZIP LU�I • ' �� <br /> LICENSE IC-42i.'C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I NEW INSTALLATION ❑ REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: I RESIDENCE ❑ COMMERCIAL I I 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 It FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES L1 LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <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 /> MINIM��M/-�p4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED /fC�C TITLE G�/JSIJLI�T7VT DATE <br /> �F yMF <br /> F r <br /> RNMCoU18 <br /> °FpyRT rq�HtY <br /> MFNr <br /> DEPARTME T UV- <br /> Application Accepted Date Area Employee ID# <br /> Final Inspection By r Date 2 11 SPECIAL PERMIT-Approved by <br /> Character of Soil to pth of 3 Ft: Pit1Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Cash Remitrted Service Re uest# <br /> S <br /> 42-Ot ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />