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VNJI I C VNAJ I tVNA 1 tK I KLA I IVItN I SYS I tM PtKMI I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-U20 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS -� EXPIRES 11 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ;-3)D LA-S PeS ITI} P 5 C I CITY/ZIP 5-1-1) <br /> 13 DCROSS STREET /I \�I/LAPN D' -6223—0 + ��.�PARCEL S¢E <br /> OWNER NAME nA/,j-JlN';>E1Z j qMA--rllq/ i�- I� r (nf&DNNE `4O�--C)?' <br /> )?' 2/— <br /> OWNER ADDRESS -'Ci CITY/STATE/ZIP cnA <br /> L9�CONTRACTOR1IVLOP0L GC0EnIvJ(2o;vrv1l5Aj-�.. PHONE rlIJ f <br /> �y <br /> b <br /> q <br /> CONTRACTOR ADDRESS 'Td w• O r1 I CITY/STATE21P <br /> LICENSE CIC-42 CC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # I BUILDING PERMIT LAND USE APPLICATION# <br /> TYPE OF WORK: :1 NEW INSTALLATION 0 REPAIR/ADornON G ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT 0 DESTRUCTION <br /> INSTALLATION WILL SERVE: C RESIDENCE C 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 TYPEIMFG 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 WELLft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R 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 /> MINIM14"44 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 r <br /> SIGNED TITLE G�.T7JSi,?.1777�T DATE I 7' <br /> E �FIVA r <br /> X'fc <br /> �o <br /> RNUI <br /> MF�'T <br /> DEPARTME TU ON rV 6 <br /> Application Accepted B Date Area t Employee IDO. <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft Pit/Sump Soil Character. <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Cash Remitted Service Re uest# <br /> 1 /-5- (?,�MS M-)Mi D V <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />