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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 /� I y� CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ,,--o Z3 I'S1��- Ln!. G'I CITYIZIP ,S TU C1KTa^j RS7-IZ y <br /> CROSS STREET Ur APN OOW -�Z PARCEL SIZE Z p <br /> OWNER NAME 77S I -`' PHONE <br /> I Jq <br /> Q /G7-I�4 <br /> OWNER ADDRESS 907'T W, 9-0 . CTYiSTATE/ZIP S- VC4--TD/1J CA <br /> CONTRACTOR LIVE Qtofy- 2NM E-y PHONE 3(pp- <br /> CONTRACTOR ADDRESS -LJ-:7W• ?T• CITY/STATE/ZIP Lob I UA ZD <br /> C1,Z40 <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # Z 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 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 f1 <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) A <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #.OF LINES LENGTH OF LINES <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ^ <br /> ❑ MOUNDED WIDTH It LENGTH ft DEPTH It G/ Z0�9 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE%n � <br /> ❑ SUMPS WIDTH It !-Y(�VLENGTH ft DEPTH /YC..-'�Ri ! CQU <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE •y��H�GPn FN7,Ad <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH f, RTMENT <br /> DISTANCE TO NEAREST WELLft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <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 /> MINIMUM, UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE L157VSULTYIT/T DATE <br /> D <br /> DEPARTMENT U E L <br /> Application Accepted By ate Area Employee ID# <br /> Final Inspection By Date ❑ SPEC AL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PitlSump Soil Character: <br /> COMMENTS <br /> PE SC Received Chec Amount Permit/Code INFO B sh emitte Date Service Request# Invoice# Permit ID# <br /> Z <br /> ��_n� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />