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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)466.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS A EXPIRES <br /> /I YEAR FROM DATE ISSUED <br /> JOB ADDRESS II A"[ V E a�✓r����'(� CITY/ZIP- lZtlR�t"Y Y►'� t7 �i�Z'Z� v' <br /> CROSS STREET 1 E AY / 7 VS-� LA's APN 0(� `1 y! p� PARCEL SIZE 114-3 A• o <br /> -1 0 <br /> OWNERNAME R-a�SAnlr.t„ } 7N STIN S'T��►J � PHONE `4-1 <br /> OWNER ADDRESS S A AM CITY/STATE/ZIP <br /> CONTRACTORVirV��EN`1r�L PHONE <br /> y, w <br /> CONTRACTOR ADDRESS 4 • OAK— S�' CITY/STATE/ZIP L'o7 ( LA CI,-40 <br /> LICENSE IC-42 IC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: LI NEW INSTALLATION i I REPAWADDITION F1 ENGINEER DESIGNED/ALTERNATIVE <br /> II REPLACEMENT L DESTRUCTION <br /> INSTALLATION WILL SERVE: I RESIDENCE ! COMMERCIAL 7 OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG 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 I 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 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ SUMPS WIDTH It LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft 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 ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft 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, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> I M 2 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953.7697 <br /> SIGNED TITLE C OTI)sVl-TPt NT DATE 2--S--2-0 <br /> All <br /> OF <br /> MENT <br /> EIVEp <br /> I CI <br /> 62020 <br /> IJOA N COUNTY N <br /> � F AL <br /> RTI►�ENT <br /> s <br /> DEPARTMENT U NL Z V,�1 <br /> Application Accepted Date Area ✓V(�-Apemployee ID# <br /> Final Inspection B Date I dffA 7 EC L P 1 SPERMIT proved by <br /> Character of Soil to pth of 3/FP"VSum Soil Cha r: <br /> COMMENTS <br /> PE SC Received Check# Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Remitted Service Request# <br /> S'i o ?)M-S <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />