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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 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 0 L- Vt'� TU N (_�. CIN/ZIP Nn fCU �Gc-/7 <br /> CROSS STREET -VL C-A APN PARCEL SIZE 1G A d <br /> -0t'3 <br /> Z 0 <br /> OWNER NAME y-�„ —C�/��7 PHONE.rliY.(Z' -0 t + Z- vl", <br /> OWNER ADDRESS r �/- •`�S-FJ�xj R r CITY/STATE/ZIP I^{,P5� `�c^ cA c1 r33tP <br /> CONTRACTOR L ( y C O,�pvy- (_rtf-C) �'W-T�Qyu' 'tuS�L PHONE 3C�{ ` -01 1' G <br /> CONTRACTOR ADDRESS I • W ( ()Vw- `�1 • CITY/STATE/ZIP ��1/ ( G� ` ��0 <br /> LICENSE IC-42 C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # 1 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 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 /> ❑ LEACH LINES ILEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE It <br /> ❑ FILTER BED WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It <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 /> NIMUM 24 H ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE P�-�' R DATE tF <br /> t L <br /> �MFNr <br /> �/VFQ <br /> l 5 ?020 <br /> Co <br /> H p FN AUNTY <br /> r <br /> J DEPARTMENT SE O LY �4RTINENT <br /> Application Accepted B C ` Data �9 O Z 0 Area ( Employee ID# <br /> Final Inspection By a -EfA(/V Date �l SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: P Sump Soil Character: <br /> COMMENTS <br /> PE SC Received hec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash Remitted Service Request# <br /> aaa sa3 1sa S 2l� <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />