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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JQAcrum COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 85202-(208)466.3420 <br /> ( NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB AoDRESS 4f6 C{y IT.Y�IZIP� L O r0-,Gy <br /> CROSS STREET !�I APN DS3 2-o _ PARCEL SIZE b <br /> OWNER NAME �/CaJs�I•}I (:��41►a L ALL7 PHONE, ,Q'} <br /> OWNER ADDRESS t✓� Nt�AC-11 U A 1...1 n-14CITYISTATEIZ1IP .S� a&VU ctn '1 C� _K`3 <br /> 1 CONTRACTOR L sS ,,Q rL uy s i2 U-_T-ic;/1 PHONE OHO 1 - C��- U�d/}U� <br /> {If <br /> CONTRACTOR ADDRESS 2ry.Z iJ. •P K7/fd�. ✓"��GITYISTATFIZJP �G�zil� <br /> LICENSE �tC-42 �]C-36 OTHER -d NUMBER SJ.So a� EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> O PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# V <br /> TYPE OF WORK: G NEW INSTALLATION ❑ REPAIRIADDITION 0 ENGINEER DESIGNED]ALTERNATIVE <br /> ' C REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: 13 RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: ;1NUMBER OF BEDROOMS' NUMBER OF EMPLOYEES: ►^� <br /> SEPTIC TANK TYPE/MlG Y 3 C0y\4-&c-1C CAPACITY ( I gal #OFCOMPARTMENTS 1 y� <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL 5-6 ft FOUNDATION It PROPERTY LINE ft <br /> ❑/ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ,43+ LEACH LINES C LEACHING CHAMBERS #OF LINES T 3 LENGTH OF LINES O It <br /> l DISTANCE TO NEAREST WELL R FOUNDATION 1 ft PROPERTY LINE s It <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY UNE ft <br /> ❑ MOUNDED WIDTH ft LENGTH It 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 WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION It PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER 3 WDTH 2-- k OF_PIl y� ft <br /> DISTANCE TO NEAREST WELL 100 ft FOUNDATION L CZ ft PROPERTY LINE � ft <br /> I f HEREBY CERTIFY THAT 1 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 /> I �l <br /> MINIIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 2D9 953-7697 <br /> SIGNED TITLE A4 c rT T DATE y/� <br /> r' <br /> On <br /> rL <br /> s. r <br /> q iu4 <br /> DEPARTMENT U e 1214L Ya <br /> Appllwtion Accc Date Area Employee fD# . <br /> Final Inspection B Date LCA 4 ❑ SPECIAL ERMIT-Approved by <br /> Character of Solt to th of 3 Ft: PwSUmp Soll C aracter: <br /> COMMENTS <br /> PE SC I Received Check#/ Amount Date Permid Invoice# Permit ID# <br /> Code INFO 8 Remitted ServiceRe uest# <br /> p ,ems z9 <br /> 42-01 - ONSfTE WASTEWATER TRTMNT SYSTEM PERMIT <br /> =1110 <br />