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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` `�t YEAR FROM DATE ISSUED <br /> JOB ADDRESS t 1&06 NUJ, �t4� ,- ` - L.�} , CITYIZIP L aD1 �S Z` Z p 4 <br /> CROSS STREET Ic7�F VN� APN Z��rIZ PARCEL SIZE �` �+ C <br /> OWNER NAME ONI`+� G� PHONE �IOr�� 4-:5 1 W4 <br /> OWNER ADDRESS � Ti CITYISTATEIZI,P�q `� <br /> CONTRACTOR T ICJ[�� cs 5t D eA � ZI <br /> C_ PHONE I tJ -36 L—z' 5-7 G j <br /> CONTRACTOR ADDRESS 101 5. �t 5�1,0,5 CITYISTATERIP <br /> LICENSE LYC-42 EIC-36 OTHER NUMBER 215``16 EXPIRATION DATE ©Z Z-8t_i_1 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> L PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIRIADDITION Ll ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL © OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES' <br /> n <br /> O SEPTIC TANK TYPE/MFG_ �s�'«Y�el CAPACITY t.7-&c3 gal #OF COMPARTMENTS <br /> O GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft 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 40 ft <br /> DISTANCE TO NEAREST WELL ! } ft FOUNDATION IO ft PROPERTY LINE v # ft <br /> 0 FILTER BED WIDTH ft LENGTH ft DEPTH ft <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 ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> O DISPOSAL PONDS WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> If SEEPAGE PITS NUMBER 2 WIDTH fv ft DEPTH ft <br /> DISTANCE TO NEAREST WELL 100 +-ft FOUNDATION + ft PROPERTY LINE So + 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 /> IM M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 // q <br /> SIGNED _ TITLE DATE 1,/ 1?A(0 # <br /> . F1aTH fMI. <br /> ' � <br /> r i <br /> DEPARTMENTU 9QN% _ <br /> Application Accepted B Date f Area Employee ID#, �f <br /> Final Inspection By Date SPECIAL PER{4�IT-ApZpved by <br /> Character of Soil to De p of 3 Ft: Pit/Sump Sail Character:___.I 4 odd <br /> COMMENTS LCZ <br /> PE SC Received (-Check ! Amount Permit/ <br /> Code INFO B mitted Date Service Request# I # Permit ID# <br /> N-rr— 6094, 2e o <br /> 42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 10I4/07 <br />