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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 CALL 209 953-7697 FOR INSPECTIONS r EXPIRES 1 YEAR FROM DATE ISSUED <br /> (1 <br /> JOB ADDRESS 43-3 �� r1V MEx_ ST- CITYrLIP MC)— ) 01 v' <br /> CROSS STREET c Hrr—o IC EF APN O5 -7 )30 4-2- -PARCELSIZE 0•'3+ ACI o <br /> per � p 0 <br /> OWNER NAME T„—'-)7JA-1- �� C��'TyDa SPr�T N PHONE !1103 --7 <br /> OWNER ADDRESS r ( 9 E • w 0 2— / ` CITY/STATE/ZIP (�mp G�--T?nN CiOi Z0 <br /> CONTRACTOR (,IV E Or` Iz— PHONE <br /> CONTRACTOR ADDRESS 40-1 k-o• CITY/STATE/ZIP LOBI L-r'1 ��Z�d <br /> LICENSE ❑C-42 ❑C 36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> [ <br /> PERE TEST # ( BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION 0 ENGINEER DESIGNED/ALTERNATIVE <br /> 0 REPLACEMENT 0 DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASETRAP TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <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 ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELLft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELLft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELLft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <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 /> INIMUUMM�/Lk�jOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED %lir TITLE � 1)'Ir�� DATE <br /> ENT <br /> AVE® <br /> 20,20 <br /> J <br /> R NTUN7V <br /> TM NT <br /> F' <br /> Lgmteo=7&1�? <br /> TMENT SE O LY <br /> Application Accepted B Area Employee ID# <br /> Final Inspection By Date ❑ SPEC AL PERMIT-Approved by <br /> Character of Soil to—pepttl of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS'Thr� A �(/zL-V <br /> PE SC Received Chec Amount Date Permit' Invoice# Permit ID# <br /> Code INFO By ash Remitted Service Request# <br /> 2 /_-Zi <br />