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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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> < t pp f_FO(2D 95 2-3-1 y <br /> JOB ADDRESS Q�I <br /> I 1 DI + � ( /SD �' D)S�N /ZD CInIZIP LocX <br /> H <br /> CROSS STREET /r�'y �� "S APN V( ` I' v+��- PARCEL SIZE d o I� v <br /> OWNER NAME (JL r"r�� LW P'HO✓NE x334- 4104 y <br /> OWNER ADDRESS V�/O `' '- %• CITYISTATE/ZIP �p0C*'-'0C*' f,Z3l <br /> CONTRACTOR Live C)I-T- Gt_0�1Vp�i10rJw1E: V 1 AL PHONE 3� I- OBl 'S <br /> CONTRACTOR ADDRESS liO, W• O1r�— ST• CITYISTATE/ZIP `0 0\ •CA Ct M4.0 <br /> LICENSE I_IC-42 '. IC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # 3 BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I.. NEW INSTALLATION -1 REPAIR/ADDITION i ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT _ DESTRUCTION <br /> INSTALLATION WILL SERVE: I RESIDENCE _: COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> x <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #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 It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft A <br /> ❑ FILTER BED WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> El MOUNDED WIDTH ft LENGTH ft DEPTH ft I� <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft 4"0 2 <br /> ❑ SUMPS WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE Zo, <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH6 _ , U/�yCO- <br /> DISTANCE <br /> 9 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 4T NM H U <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft UFpq/pT�gt��ry <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 /> MINIMUMUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 q <br /> SIGNED TITLE G0fjyyL-��r`'rT DATE <br /> ARTME O LY <br /> Application Accepted By Date Area Employee ID#_�� <br /> Final Inspection By Dat '.I SP IAL PERMIT-Approved by <br /> Character of Soil to nth of. r• Pit/Sump it Charact r: <br /> COMMENTS ( M• 4 R l m <br /> 1 <br /> PE Sc Received Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash Remitte Service Re ues <br /> Z <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />