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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 A� CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS mLo hy,`mr �w 2 <br /> CRYMP 0-1 P� 7 <br /> CROSS STREET t�r�P►'(r�`' Z (� APN 2A 0 O C1 PARCEL SIZE I �� p <br /> p `I <br /> OWNER NAME F'hy DAJ I DS riJ PHONE <br /> OWNER ADDRESS A-�� CTTY/STATEIZIP <br /> CONTRACTOR LI V C- 0 t0i(--7 &E�O&W 1l!R0eJ&1 E:Pa +4L- PHONE 3&cf`0 37 <br /> CONTRACTOR ADDRESS moi' 1 Wy Ale- ST' CITY/STATE/ZIP L 0C>1 LI�p 1 1:1 Y-2,0-4 0 <br /> LICENSE C-42 C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIRIADDITION 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 /> ❑ GREASETRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION R 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 it FOUNDA"TION ft 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 R <br /> DISTANCE TO NEAREST WELL fl FOUNDATION ft PROPERTY LINE It <br /> ❑ SUMPS WIDTH ft LENGTH it DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELLit FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH it 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 /> IMUM 24 H VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE NS U LT fY NT DATE <br /> RFq�'MF <br /> I cF��or <br /> qR 16 ?0 <br /> A)4*s <br /> �co <br /> Fpq�NNrY <br /> EPARTMENT USE ON Y <br /> Application Accepted Date__ I �In Area Employee ID# <br /> Final Inspection By \ Date_ [r/ SPECIAL PERMIT-Approved by <br /> Character of Soil to pth of 3 Ft: P um Soil Character: <br /> COMMENTS <br /> PE SC Received a Amount Date Perm iU Invoice# Permit ID# <br /> Code INFO B ash Remitted Service R est# <br /> 222 2 151- ` <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />