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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT $J� <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 1 YEAR FROM qR DATE ISSUED <br /> JOB ADDRESSQM CITY/ZIP ` LA <br /> :.I <br /> CROSS STREET APN PARCEL SIZE WXAC& � <br /> b <br /> O <br /> OWNER NAME ��� Tw�-l�/�.�,V, �I�' Q i(�' PHONE <br /> /,�Q <br /> OWNER ADDRESS 1 y fdQe4 A`i 1 CITY/STATE/ZIP VV i ' I�(-�YI ^o ,— �W- 1 � A ` <br /> CONTRACTOR lv�I O � � �/l./+ PHONE 2x - �67 / /Q ( 16;'A aq_ 1v <br /> CONTRACTOR ADDRESS A I CITY/STATE/ZIP <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: I NEW INSTALLATION I 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 /> ❑ 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 /> L3LEACH LINES LEACHING CHAMBERS t� Li MFJOF LINES ft <br /> DISTANCE TO NEAREST WELL ' OUNDATION PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH Permit mav_h va P erred withIwi ft <br /> DISTANCE TO NEAREST WELL �'ynpE '(r} h!p!�rOPERTY LINE ftIV Ulf% <br /> ❑ MOUNDED WIDTH ft LENGTH -DEPTH ft <br /> ,I `N] <br /> DISTANCE TO NEAREST WELL F0n I M " '�Y�'r, I)l�i� PROPERTY LINE ft <br /> ❑ SUMPS 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 ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> HOUR ADVANCE NOTICE REQUIRED FOR INSNS-Pl CALLg0 -�797p)953 <br /> SIGNED _ TITLE C la�UXDATE Z41 <br /> I-k V13 <br /> l <br /> r � <br /> Ifl JO I <br /> i ! tt I I.ci 0 N I E <br /> 4" 1 <br /> DEPARTMENT U E O Y 116 <br /> Application Accepted By Date �� �� Area Employee ID# <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 Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash Remitted Service Request# <br /> s u 3 9 D c u.cv i SIn <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 10/4/07 <br />