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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(208)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> -1 E. s�tQ(j(,f J ��• CIn21P L Ot> 1 91 Z` O <br /> JOB ADDRESS 15' I S� <br /> CROSS STREET TVAPN o53a-10-txP rD-1 -6 PARCELSIZE I pI <br /> OWNER NAME M ) [ C- PHONE -71 <br /> LLf' >b <br /> �e <br /> OWNER ADDRESS SAmt CrrY/STATE/ZI'P7 (� <br /> CONTRACTOR LAVE 01I r� &EO Q'J\r120��I C'v 1 ,1 PHONE J to / <br /> CONTRACTOR ADDRESS Tc-7 w• O'" ' S I - CITY/STATE/ZIP <br /> LICENSE QC-42 QC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST #- -- BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAWADDITION ❑ ENGINEER DE IGNED/ALTERNATIVE <br /> 0 REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE C COMMERCIAL 0 OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL it FOUNDATION ft PROPERTY LINE it <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES 0 LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH it <br /> DISTANCE TO NEAREST WELL it FOUNDATION R PROPERTY LINE It <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It - <br /> ❑ SUMPS WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELLfl FOUNDATION ft PROPERTY LINE it <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it <br /> ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH It <br /> DISTANCE TO NEAREST WELL ft 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 /> IMUM 24 ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 G <br /> SIGNED TITLE C Q NS V L--,r - DATE <br /> —1 <br /> AYMENT <br /> ECEIVED <br /> EP 10 2019 <br /> g JOAQUIN COUNTY <br /> VIRONMENTAL <br /> LTH DEPARTMENT <br /> DEPARTMEN S ONLY c /� <br /> Application Accepted By Date Area Employee ID#� <br /> Final Inspection By Data C3 $�/AL ERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Characte <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO IXY Cash Remitted Service Re uest# <br /> L/ <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />