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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 /> r NON-REFUNDABLE <br /> PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ` JOB ADDRESS -1 S "P0'-j CIN/ZIP ESGPI-Ii6� �� 3Z'� <br /> H <br /> CROSS STREET C A-9--f e tz_ APN Zt7-1- C)(.PO-39 PARCEL SIZE 3-31 In• p <br /> OWNER NAME t`i L ftA-?—D PHONE Zo _ �14 3 w <br /> OWNER ADDRESS '9333� -ACC>I tE: L-Q • CITY/STATE/ZIP E^SC A L-`)N c^ 01 Y32-0 <br /> CONTRACTOR 1­1 V'`rryC 0- `1 � <br /> 6r-C 0 L)wj V)R-Orj M t' rA L- PHONE 3&11 11t _0 3 1 J <br /> CONTRACTOR ADDRESS 40-1 w• or,K S ' • CITY/STATE/ZIP LOD) A G I S 2`1716 <br /> LICENSE ,.:C-42 IC-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 I I REPAIR/ADDITION 1 1 ENGINEER DESIGNED/ALTERNATIVE <br /> - REPLACEMENT it DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE I 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: VVELL 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 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 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH It 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 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 /> A,INI,MUM 24XPR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED / TITLE DONS✓L%� T DATE &—L - <br /> � A, <br /> w <br /> ? , ?019 <br /> C <br /> DEPARTM <br /> Application Accepted Date E Area Employee ID# <br /> Final Inspection By Date I SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Char cter: <br /> COMMENTS �Q` 4,r6yi r-a 3$. ilt;'t f"n C <br /> PE SC Received Chec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Remitted Service Reg uest# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />