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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 /> NON-REFUNDABLE PERMIT <br /> _ CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS " lU 10 S' P�Eesa� PPcSS �p, CITY/ZIP <br /> CROSS STREET SAO APN 2-o17-t av-44 l pT!'-M J PARCEL$ILE ��+ A <br /> e <br /> OWNER NAME SIT w-,Vt_c.N 1 N C• PHONE I Z$-ZSO- SS7 a y <br /> OWNER ADDRESS �' 0' Jd/� ( puCITY/STATE/LP CAel-rOLA CA 7Sol o <br /> CONTRACTOR 1^'(J E 0814— Ge 0 F-�V)e-aJrVk l A L- PHONE Z'0G) - 3(Vel 0 <br /> CONTRACTOR ADDRESS w• OAV— ST• CITY/STATE/ZIP L-01>1 GPr �5-Zfo <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: NEW INSTALLATION 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 TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal tI 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 - 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 It DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELLR FOUNDATION ft PROPERTY LINE It <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 /> ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953.7697 q <br /> SIGNED TITLE cwt--�RST DATE <br /> AA y4f, <br /> Z 21719 <br /> RCN�IV COU <br /> Ty D�p�RTMFN�, <br /> to <br /> s <br /> IL <br /> PARTMENT USE ONLY n <br /> Application Accepted By L Date I Z '1 Area Employee IDI Ill y <br /> r <br /> Final Inspection By Date �' SPECIAL PERMIT-Approved by <br /> Character of Soil to Depgth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTSi ' 11r'et� t au} cnJnflr sail urtllr Ut f LfD e' <br /> PE SC Received Chec Amount Date Permit/ Invoice# Permit 11 <br /> Code INFO B Remitted Service Re ues <br /> 42-Ot ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />