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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> WON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /L' 1% 'C �^ CITYIZIP C' <br /> CRO55 STREET APN [q/�7«� 7 'Z PARCEL SIZE S toi <br /> d <br /> '/ z <br /> OWNER NAME ////9l! /7I a :f�i{JC�/ PHONE GYM- D�3i <br /> OWNER ADDRESS / Q CITY/STATE/ZIP <br /> CONTRACTOR r/�i�/� r �E�s� /% PHONE <br /> CONTRACTOR ADDRESS ?�/G C'/�-�-�z �7.0 CITY/STATEIZIP <br /> LICENSE ffC-42 I,IC-36 OTHER NUMBER /C' ' EXPIRATION DATE <br /> WATER TABLE DEPTH: _ _ f2 GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: Lj RESIDENCE )!kl COMMERCIAL I_I OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: _ <br /> 1 <br /> SEPTIC TANK TYPE/MFG T! CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> I <br /> DISTANCE TO NEAREST: WELL. tri ft FOUNDATION HG ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT U SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> [� LEACH LINES LEACHING CHAMBERS jill+s -,;2`1 #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL '/1w ft FOUNDATION <-G ft PROPERTY LINE x R <br /> ❑ FILTER BED WIDT14 ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ SUMPS WIDTH ft LENGTH 1t DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WID1H It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST VJE_L ft FOUNDATION ft PROPERTY LINE ft <br /> 13 SEEPAGE PITS NUMBER_ WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST V.E__ ft FOUNDATION ft PROPERTY LINE 77 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL 209 953-7697 <br /> SIGNED l ` TITLE _ r NC..t -�`.' C" DATE <br /> G <br /> Nu U <br /> i <br /> I � <br /> �13 <br /> I'a <br /> l r DEPARTMENTUS ONLY <br /> Application Accepted ay Date l Area Employee ID# <br /> Final Inspection By _ — f L'e .'r' Date -' LI SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS A)ci-J 'cr i-: gnCz2rip <br /> PE Sc Received C_h _ Amount Date Permit] invoice# Permit ID# <br /> Code INFO as Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 9!21!10 <br />