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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"°FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOBADDRESS E-' CITY/ZIP <br /> y <br /> CROSSSTREET /y�(7y�J/{ Cpl APN �" 'S-.2'3C-3d PARCELSIZE p <br /> - �j 1 <br /> OWNER NAME ry� �O(.V bP�� PHONE <br /> OWNERADDRESS JA7"� )) CITY/STATF/ZIP�,pO.II <br /> CONTRACTOR C- 71 PHONE J6 <br /> CONTRACTOR ADDRESS 1 CrrY/STATE/ZIP farLOC <br /> LICENSE O C-42 O C-36 OTHER NUMBER EXPIRATION DATE 0 - <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: Q NEW INSTALLATION IiK REPAIR/ADDrr10 ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> WREPLACEMENT DESTRUCTION OL-,o 1N(L- <br /> INSTALLATION WILL SERVE: urR..NCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNIT'S: N UMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TVPF/MFGEL Ce N911t�t CAPACITY J9'00 gal #OFCOMPARTMENTS.— <br /> ❑ GREASE TRAP TYPF/MFG CAPACITY gal #OF COMPARTMENTS. <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL 00 ft FOUNDATION ft PROPERTY LME /5�01 ft I`I <br /> Cl LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 171, LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES <br /> I DISTANCE TO NEAREST WELL (CLQ fl FOUNDATION fl PROPERTY LINE <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft I11 <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 ft PROPERTY LINE <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft �N <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST -- WELL ft FOUNDATION ft PROPERTY LINE ft N <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> �J,INIMUM�(�\�i T,UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 J I7 <br /> SIGNED r r V,V�Xx7� TITLE CO V 1' 9%c-t�y S� DATE <br /> I - <br /> tl <br /> 4 `"L S <br /> { I t. <br /> E N o <br /> H E <br /> O <br /> DEPARTMENT U'E O.'LV <br /> Application Accepted B _ / Date (7 Q-� Area Employee ID# <br /> Final Inspection By Date/f- a`lV ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS /VEcv "-ryF 4&rc)AA C"N-7i-IZ � <br /> PE SC Received hecldi/ Amount Date Permit/ Invoice# PermitID# <br /> Code INFO B Cash Remitted Service Request# <br /> 2-to ((S (LoD4 <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> 1 v22r2oG <br />