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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202 - (209) 460+3420 <br />NON-REFUNDABLE PERMIT (2009 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUE[ <br />JOBADDRESS C>OS,,..S <br />w �1 /SCALL <br />GAc6L-FJ7Ct �./f , <br />CITQpY}�IZIP A—D <br />, eiS`s <br />CROSS STREET <br />WVVZTF t�� APN IOi-'LOQ' <br />O1 <br />PARCELSIZE <br />OWNER NAME , <br />R Doi -- =,A, <br />17 MOUNDED <br />PHONE <br />OWNER ADDRESS <br />-d�,e— <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />CONTRACTOR S�+-�'`� <br />f�CRY/STATE/ZIP <br />c�-L%� T7� $ <br />p y <br />PHONE 'i— -�)� <br />CONTRACTOR ADDRESS '004 AVE 10-5 <br />CnY/STATE/ZIP <br />(2,ik LIS-LI440 <br />LICENSE IPC -42, <br />❑C-36 OTHER NUMBER I J S'ib <br />EXPIRATION DATE <br />n Z.r z,�s j t t <br />PROPERTY LINE <br />ft FOUNDATION ft ft <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />LJ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION #, <br />TYPE OF WORK: D NEW INSTALLATION _ REPAIR/ADDITION .7 ENGINEER DESIGNED /ALTERNATIVE <br />❑ REPLACEMENT D OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: 2� RESIDENCE D COMMERCIAL 0 OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: L4 NUMBER OF EMPLOYEES: <br />Q SEPTIC TANK TYPE/MFG ��"j� ?rC 01 S CAPACITY �C) gal #OF COMPARTMENTS <br />O GREASE TRAP TYPEIMFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION It PROPERTY LINE It <br />O LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES <br />VL LEACHING CHAMBERS <br /># OF LINES ) LENGTH OF LINES (40 ft <br />DISTANCE TO NEAREST WELL <br />+ <br />IOQI 4 -ft FOUNDATION -,D ft PROPERTYLINE -3O 1 ft <br />O FILTER BED <br />WIDTH It <br />LENGTH It DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION It PROPERTY LINE ft <br />17 MOUNDED <br />WIDTH ft <br />LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />O SUMPS <br />WIDTH ft <br />LENGTH it DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />O DISPOSALPONDS WIDTH ft <br />LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />PROPERTY LINE <br />ft FOUNDATION ft ft <br />SEEPAGE PITS <br />NUMBER !r <br />WIDTH Cs �~ S' DEPTH �Z�S I It <br />DISTANCE TO NEAREST WELL <br />i <br />100 r't' ft FOUNDATION 36 + ft PROPERTY LINE SLG 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 <br />RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />M"MtW <br />24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED <br />J"'w{� <br />TITLE C0 -11+-1r-1--41— DATE, Ie ` )l <br />Application Accept <br />Final InspectionBy <br />Character of Soil to pth of 3 Ft: <br />COMMENTS - /7 <br />i <br />7 <br />0 <br />TM -E -N _U.S.. _O'N'L'Y-� ?� <br />Date �I Area Employee ID# � 9 <br />Date 2 L ❑ SPECIAL PERMIT - Approved by <br />Pit/Sumo Soil Character: <br />PE SC Received ec Amount <br />Code INFO B sh Remitted <br />Date Permit/ Invoice # Permit IDN <br />Service Re uest # <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />6/26109 <br />