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��—QNSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENNRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL(2009)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> I JOB ADDRESS X-247-12 /'/VMW S7 aL M <br /> f9 orV rACE CiTTY21P eA Pt 7 PSZ 2 V FR^ <br /> CROSS STREET aELTI ine ,2Or4-L APN O!3"'170-a,5 PARCEL SIZE`' 3-S9 c <br /> OWNER NAME ('I,Q,�J-DfIA/ 9"AllVa PHONE <br /> OWNER ADDRESS Ou Cmc/-' ST-l�T. 9 g Cmr/STATE/ZIP/ ,Po '7SL LCJ <br /> CONTRACTOR QW 012,6d&17/ " PHONE- /,/,��-/��14,'9.7 <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS I © gc—,X 37 1t 4 CITY/STATE/ZIP !L(IZ L LSA 9S-3P l <br /> LICENSE 0C.42 ❑C-36 OTHER NUMBER <br /> NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ( � ft GEOGRAPHICAL INFORMATLON: Coordinates X Y <br /> PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: 0 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 /> ❑ SEPTICTANK TYPE/MFG CAPACITY <br /> 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 /> N <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ FILTER BED WIDTH ft LENGTH It DEPTH ft V <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE /t C� <br /> ❑ MOUNDED WIDTH R LENGTH It DEPTH ft Z <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> (3 DISPOSALPONOS WIDTH It LENGTH It DEPTH ft c <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It 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, �(1 <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. I <br /> }ny^M HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 ,p Q <br /> SIGNED rr!` TITLE J A� DATE <br /> 1 <br /> 51 <br /> i <br /> i <br /> VR M N AL Q <br /> � C <br /> � I t <br /> i <br /> i <br /> :a �._ ter• ...6EPA7tTMENTUSEONLY z-� -' ---- <br /> Application t Date !`t D� Area Employee ID# -_Y�G Q? <br /> Final Inspection f Date ��Y✓/off ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PiUSump Soil Character: <br /> COMMENTS <br /> �/Z 3' Gfzc�� �O CSO UrnlUz � /��� / <br /> PE SC Received Amount Date Perm Invoice# Permit ID# <br /> Code INFO ash Remitted Service R uest# <br /> �a2y sf oo SS -1 <br />