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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> 1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-76)97 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �}�y� <br /> JOB ADDRESS Z'� 0 N ftkc�c G-S IAV C CT• CIN/ZIP C L CW E NTS 41577-2--1 <br /> CROSS STREET �0��0 APN 1 �' 011 PARlCEL$RE�(I O'-7 1 �• o <br /> OWNER NAME `V is PHONE -2 <br /> OWNER ADDRESS •�+/�'�• "�L �G ` '���-�;-,� CITY/STATE/ZIP <br /> CONTRACTORLL�t,tD 1 ��/. (Tf.../O,GSI`/�w— PHONE 3(O� - <br /> CONTRACTOR ADDRESS 14D� W V' ^ -5-r' CITY/STATE/ZIP '-O t>l C^ � Q <br /> LICENSE C-42 C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # LBUILDING 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 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 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 It PROPERTY LINE It <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It 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 /> INIMU UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED ( TITLE DATE `G�o <br /> PAYMENT <br /> Viet) <br /> AR 16 ?020 <br /> ON SN-rAL <br /> DIE <br /> RTIl1ENT <br /> 10 <br /> PA <br /> WID Application Accepted By Area Employee ID#Final Inspection By 0 Zd201 1 SPECIAL PERMIT-Approved by <br /> Character of Soil to th of 3Pi Sump Soil Character: <br /> CO MENT <br /> PE SC Received heck Amount Permit/ <br /> Code INFO ash Remitted Date Service Re uest# Invoice# Permit ID# <br /> 344 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />