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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 /> NON-REFUNDABLE PERMIT p CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROMDATEISSUED <br /> JOB ADDRESS �I`IV�G� �A• CmZP /Vift N"TE C�1 S3J� <br /> 23 v ZZCo-!l0- <br /> CROSS STREET �� APN I� � —� PARCEL SIZE 2C � i <br /> b <br /> OWNER NAME IA Kt` - I Tu- -t" DMD F—Cbb N NJ PHONE Uo[C) — <br /> OWNER ADDRESS CRY/STATEZP �NT <br /> CONTRACTOR L-I V E oPCK C 'DE��1(��m EN'ft�L.. PHONE 3&ci-03+5 <br /> �� � <br /> CONTRACTOR ADDRESS ' O'-`MlC <br /> ► 77• CITY/STATEZP <br /> LICENSE QC-42 gC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # Z BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ 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 /> ❑ SEPTIC TANK TYPEIMFG CAPACITY 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 /> ❑ LEACH LINES ❑ 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 A <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH A�j� <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE-- �ft ,'/jam <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH /7.4LiR 7CC� <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE S%.t. ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH `'— E,fX� 019 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE N C <br /> C3 SEEPAGE PITS NUMBER WIDTH ft DEPTH �7f+AiO�/�/T_ <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <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 /> y MINIMUMMI"%lly OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 Z <br /> SIGNED /� TITLE C C A/f V C.I rt-uT DATE <br /> DEPARTM T U E 0Nl1� <br /> Application Accepted By Date Area tZ Employee ID# <br /> Final Inspection By Date 11 SPE IAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft Pit/Sump Soil Character. <br /> COMMENTS <br /> PE SC Received hec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO ash I Remitted Service Re uest# <br /> Z � / � 34936 124 32� <br /> e�_n� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />