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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 /> N6N-REFUNDABLEHHPE-7RMIT �( }�,CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS "y 1 1 VC+"S�/ �d <br /> CITY/ZIP <br /> �-�jlC YY1�0 t �/ry 'ZCROSS STREET APN �V�— �D PARCEL SIZECI�ZQZGO Iy <br /> Gu. <br /> OWNER NAME tlefn Ti(f V ,jPHONE 417- -ae,3 7 � <br /> J <br /> OWNER ADDRESS {�L W Ta aJJ '. ,A CITY/STATE/ZIP PZ <br /> lid(.'Pi r" <br /> CONTRACTOR D,::: � V V 1 1 q (^�'1�q-: 1 I JVl I- PHONE % —���I <br /> CONTRACTOR ADDRESS _ 1:11-2� I l lIO�a 4'1 y 12A CITY/STATE/ZIP f�J�. VN r o <br /> LICENSE LC-42 �C-36 OTHER 1/.1:11-2 NUMBER `670'a ExPIRATION DATE <br /> WATER TABLE DEPTH: b(/ ft GEOGRAPHICAL INFORMATION: Coordinates X Y ^, <br /> U PERC TEST # BUILDING PERMIT# _G LAND USE APPLICATION# <br /> TYPE OF WORK: _ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> C REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ] COMMERCIAL D OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY <br /> gal #OF COMPARTMENTS <br /> L3 GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE tt <br /> LIFT STATION — SIZE TYPE OF PUMP 12 PKG TX PLANT O SAND OIL SEPARATOR( NCLOSED SYSTEM) <br /> Sa�0 <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 It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH tt DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO REST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 13 SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DIST ETo NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT I PREPARED THISAPPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> ST LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE <br /> I <br /> cT Z7 a <br /> p b 6 <br /> 9 <br /> s <br /> i td �� o , <br /> SAN <br /> a N <br /> �y at Nr <br /> DEPARTMET E LY <br /> Application Accepts Date Area Employee Il?# <br /> Final Inspection By ate / ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to D th of 3 Ft: - q Plt/Sump Sod Character: <br /> COMMENTS <br /> PE SC Received heck#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Remitted Service Request# <br /> s <br />