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low <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)4613-3420 <br /> f NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1/YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY21P A <br /> �j� /J <br /> CROSS STREET=T7 <br /> APN 102 <br /> J `7V r O PARCEL SIZE L t p <br /> G <br /> OWNER NAME �^ eA PHONE Czar)222 2MP <br /> W <br /> OWNER ADDRESS /(/70 / CZ!/l _ CITYISTATI/ZIP AS-40c" PA 9_<-Z1.7- <br /> CONTRACTOR �/1/ PHONE 3 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> i <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> f ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# ' <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATI <br /> F1 REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION . <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LNING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> O 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 11 P.KG 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 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 It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBED 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 /> MINIMUM 24 HOUR ADVAN E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL(209)9053-7697 <br /> SIGNEEN 1a TITLE /)i1YIIf DATE <br /> IECEIVED <br /> IF <br /> ElIVRONIVINTOL <br /> 4- <br /> - _ P- ATMENT NLY - 197 __ <br /> IE Application Accepts Date 1AArea Employee ID <br /> r �Z?�// ❑ SPECIAL PERMfT-A roved b <br /> Fina!Inspection B Datewo <br /> pp y <br /> I Character of Soil to epth of 3 Ft: Pit/Sump Soil Character: <br /> i <br /> COMMENTS D '7Af-/JAG <br /> �a,AeY 6fj? "-S i,::2 C*rF --fzt,929-4—�i�c r�%i�/i�. y�L/ii 9,z&i A, <br /> PE Sc Received C Amount Permit) <br /> Code INFO B Remitted Date Service Request# Invoice# Permit ID# <br /> 1:7K "e <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 6126109 <br />