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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 L cCALL(2`09 953-7697 FOR INSPECTIONS ^I p EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS .32-3 ) <br /> I�� E G.pS PI V S I`"�L CITY2ZP fit, ay <br /> CROSS STREET C �'y�'1 I I K) �"j "'•-- APN 0 OS PARCEL SIZE Z• /'�C.. tj <br /> 0 <br /> OWNER NAME TO nl�� �-i'C PI E 121z s PHONE '3 7- -""1 - 5*;�1 y <br /> OWNER ADDRESS /S M E CRY/STATE/ZIP <br /> V ? <br /> CONTRACTOR I-I E 0Y-- TE Oyr, 1I II'�O�m EN 1 I r L PHONE 3(191`r - D•�7 S,,/� <br /> CONTRACTOR ADDRESS c-7 w Q�`� S ( . CITY/STATE21P cA <br /> (••��( R S��y <br /> LICENSE QC-42 QC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> �Q PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ 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 TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft 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 ft DEPTH ft <br /> DISTANCE TO NEAREST WELLft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELLft FOUNDATION R PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELLft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELLft 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 /> INIMUM;kFI0!PR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED //`` TITLE cavi U(-7fj7JT DATE le - 11-19 <br /> PAYMENT <br /> ECEIVED <br /> i N 18 2019 <br /> AQUIN COUNTY <br /> IRONMENTAL <br /> DEPARTMENT <br /> I <br /> G <br /> EPARTMEN US ONLY <br /> Application Accepted By v Dateliq Area Employee ID# �l h' <br /> Final Inspection By % Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 F Pit/Sump Soil Character. <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service R uest# <br /> , <br /> Z -1 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />