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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 EXPIRES <br /> 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 2 V I S• , —r• 90. CIN/ZIP A(Pe-AJ -r S-�ca f <br /> CROSS STREET WEST 2t PO YJ APN ZZ 6 0 -3 T PARCEL SIZE ( I rk' p <br /> OWNER NAME �)KK- �•�LI aUi_ PHONE <br /> OWNER ADDRESS 1 3 3 3 �Kl� • T T CITY/STATE/ZIP i21 P Ry J c-A S3(y Le <br /> CONTRACTOR L'L V F- O K1- GCOF?jVUZoNyhLM t M-L- PHONE 31011- 03-7 f <br /> CONTRACTOR ADDRESS LfD-j K.)- OPOe- ST. CITY/STATE/ZIP (-UDI C-�R /S2 -0 <br /> LICENSE C-42 C-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: NEW INSTALLATION REPAWADDITION i.. 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 It FOUNDATION ft PROPERTY LINE It <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> PA <br /> 13LEACH LINES 1 i LEACHING CHAMBERS #OF LINES LENGTH OF LINES A� M�'•Iwr <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH It DEPTH YYY <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE JU ?020 <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE 'IN Cc)UN7y <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH HPnt pAI <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE E ARTMnELNT <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> 1 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 UM 24 HO VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE P/'-OJ ✓r1C7/Z DATE <br /> DEPARTMENT IISEENLY <br /> LApplication Accepted �— Date0.77 Area i C Employee ID# <br /> Final Inspection By NA 1 SPECIAL PERMIT-Approved by <br /> Character of Soil to DZth of 3 Ft: it/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Remitted Service Request# <br /> a sa3e- <br /> q;;' <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />