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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202.(209)466-3420 <br /> NON-REFUNDABLE PERMIT / CALL 209 953-7697 FOR INSPECTIONS ExPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Z5 F-LnG(1 Cu mp ✓ CITY1zPP S,t-OC_L<4-011 <br /> CROSS STREETl D�J�`tis�-U APN <br /> —OB V !.— PARCEL SIZE �_ <br /> SI�CId 7 y< � <br /> OWNER NAME (U✓I ✓hL�!e!/' PHONE <br /> OWNER ADDRESS IO�X ✓ S Y- CITYISTATE/ZIP q �B}•�py' lL 1/ <br /> CONTRACTOR �C�l N'�/ U!s I�1% DL►'N�( � PHONE C—y-7�( (O- q7 v Y/(tom <br /> CONTRACTOR ADDRESS I�U to r �N� CITYISTATE/ZIP <br /> LICENSE QC-42 QC-36 OTHER C-21 NUMBER v, I EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE TION# <br /> TYPE OF WORK: G NEW INSTALLATION ci REPAIR/ADDITION Q ENGINEER DES] NED/ALTERNAT E <br /> G REPLACEMENT 0 OUT-OF-SERVICE SEPTIC SYS M D TRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE n COMMERCIAL ❑ O R <br /> NUMBER OF LMNG 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: WELLft FOUNDATION ft PROPERTY LINE ft <br /> ❑ UFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES 0 LEACHING CHAMBERS #OF LINES LENGTH OF LINES it <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE it <br /> ❑ FILTER BED WIDTH ft LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ MOUNDED WIDTH ft LENGTH it DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it <br /> ❑ SUMPS WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH it DEPTH it <br /> DISTANCE TD NEAREST WELL ft FOUNDATION 11 PROPERTY LINE tt <br /> ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH It <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 /> NIMU OUR AD CE NOTICE REQUIRED FOR INSPECTIONS-//PLEASE CALL 209 9/5�3-7697 <br /> SIGNED TITLE COLA lin'f T�('JN DATE <br /> �ill I 7PIF11-f I <br /> - - - - - - <br /> EPARTM N SE NLY I <br /> Application Accepted 8 Date Area Employee ID# <br /> Final Inspection By Date 2=- U SPECIAL PERMIT-Approved by <br /> Character of Soil to Glepth of 3 Ft: Pt Sump Soil Character: <br /> COMMENTS 140aZ <br /> PE SC Received eck Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash Rernitted Service Request# <br /> 7,0 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 9/21110 <br />