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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209)95/3�-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �1 (0 -I D Gi- M EC-TD N "n CITy21P ►�PC�I� C h <br /> CROSS STREET I,NA r r r-�I-CL A P - APN -7 S -- 2-2­0 - 3� PARCEL SIZE <br /> OWNER NAME M Tl 111 NJ G PHONE W' Z -D 1-3 Z In <br /> OWNER ADDRESS ,I PwS-TSIV '`v ' CIT//STATE/ZIP M� \N'NEt7C� CA 33(,p <br /> CONTRACTOR (-)J E Q P�Y— &CV F- 1V ItI?-07,Jr1AENT^L- PHONE 3 IPJ-03-1 S <br /> CONTRACTOR ADDRESS 40-1 (-j- Q PCIL ( CITY/STATElTJP (--off( Cl, -1 T-2-1;4-0 <br /> LICENSE QC-42 ❑C36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft- GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST #____L_ BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ., REPAIR/ADDITION ❑ ENGINEER DESIGNED IALTERNATNE <br /> Cl REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASETRAP TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <br /> DISTANCE To NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFTSTATION SIZE TYPE OF PUMP ❑ PKGTXPLANT ❑ 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 R <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft 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 ft DEPTH ft <br /> DISTANCE TO NEAREST WELLft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It <br /> DISTANCE TO NEAREST WELLft FOUNDATION ft PROPERTY LINE It <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 /> MINIMU HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 '/ G <br /> SIGNED TITLE G�NfyI-I�� DATE T- ^� J <br /> �Aqy <br /> 0511 <br /> alco <br /> L LA <br /> c <br /> I I <br /> I <br /> f <br /> I <br /> t- DEPARTIMENT E O <br /> Application Accepted By Date Area Employee ID# Agow <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 ec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remitted Service Re uest# <br /> 1,5-7D SZ '42-11 -5�4 U0�U S4�c <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />