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W1101 I C YYAA I CYYA 1 CIG 1 ICDA 1111111:1`111 J T A I CIYI 1'c R1Y11 I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EMAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES'I YEAR FROM DATE ISSUED <br /> Joe ADDRESS a' ��t+ry�.}• p- N, rrw . 99 e cn,/zIP kcnw(.no 9Suo <br /> CROSS STREE;14p�JMtA Aj-T ��v �� Ap �00K'I-f(x0-1S' III yAAR�51AE <br /> OWNER NAME I AOIH L�CH `T��FJJ-,,V••``�+� IC+V�C /UGF7. �t 001 <br /> OIFS'Z'�Y?-C"2'FS3b <br /> • OWNERADDRESS Z-T � fAw Ll / /STATERIP Ac-ftmf0 <br /> CONTRACTOR 4\JE OP(V-- GEO F?�UI(trt��r.1J�MENi1°CL_ PHONE 31o9-d3�'SAA QR �( <br /> CONTRACTORADORESS LFD�- W- OPC�OA-V-- > - Cm'ISTATFJZIP L.o�I CA Z-4-o <br /> LICENSE QC-42 QC-36 OTTER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: It GEOGRAPHICALINFORMATION: CDorrdlnaWs X Y <br /> QL' PERCTEST # l BUILDING PERMIT# LAND USE APPLICATION <br /> TYPEOF WORK: ❑ NEWINe'ALIATON ❑ REPAIAADDITION ❑ ENGINEERDEGIGNEDIALTERNATVE <br /> ❑ RE ACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: O RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LNING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TWFJMFG CAPACITY gal #OF COMPAATMENTs <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <br /> DISTANCE TO NEAREST: WELL It FOUNDATION It PROPERTY LINE ft <br /> ❑ UFTSTAT10N SIZE TYPE OF PUMP ❑ PKGTXPLANT Cl SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OP LINES LENGTH OFLINES It <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED VaoTN It LENGTH it DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION It PROPERTY LINE It <br /> ❑ MOUNDED WIDTH ft LENGTH It DEFTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE It r+G9 ay� <br /> ❑ SUMPS Nm It LENGTH It DEPTH It <br /> DISTANCETONEAREST WELL it FOUNDATION ft PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH It LENGTH It DEFTlH It /I <br /> DISTANCE TO ft NEAREST WELL R FOUNDATION PROPERTY LINE ft AfA <br /> ❑ SEEPAGE PITS NUMBER WIDTH it DEPTH <br /> • DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE E JOgQU/N <br /> I HEREBY CEIRTHFY THAT I HAVE PREPARED THIS APPUCATON AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANC " I /Roth OOu, <br /> ��//J,/ry1�'t(�I STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. NQ�a nN7A <br /> /<i`✓"' / !•-'SOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS.PLEASE CALL(209)953-7697 � •E•lNT <br /> SIGNED TITLE GDNSt/(�l'FlNT DATE <br /> ------- <br /> �tY � <br /> �4 <br /> FF _ ® I <br /> �- .s 9TATB <br /> P <br /> DEPARTMENTE <br /> YSOtiLyO <br /> Application Accepted Date Area Employee lD# <br /> Final Inspection By. Date ❑ SPE AL PE R-Approved by <br /> Chamoter of Soil to Depth of 3 FD Pit(Sump Soil Character. <br /> COMMENTS <br /> • PE SC Receivetl Lh AmountPermW Invoice# Permit IDN <br /> Cotle INFO Cash Remittetl get., SerAmR nest# <br /> / <br /> 3 1 D6- <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMR <br />