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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> } SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)]953-7697 FOR INSPECTIONS � /��EXPIRESg1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 5-q 2-0E C. AC100"PID r✓• CITY2 / C1P A�•'�P o / Z�./ ' <br /> CROSS STREET KENNE rit GK APN 01� 3" - o-3 PARCEL SIZE I'�' �• p <br /> OWNER NAME 1-fftnlAA PHONE trod '141 V <br /> OWNER ADDRESS 5AWf, 0 <br /> CITY/STATEIZIP <br /> CONTRACTOR L4%lE L00j� uG��—^'V�tf1`�QU��T��— PHONE 3�- 07Q (I <br /> CONTRACTOR ADDRESS f_-q IIS' OAK ' . CITY/STATE/ZIP L-UD I <br /> LICENSE I_C-42 C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAWADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL I I 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 ft FOUNDATION ft PROPERTY LINE It <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES I LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft 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 WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft 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 /> INIMUI��A???3d����000UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 q G <br /> SIGNED TITLE GQ'1'VSULTYf7�/7 DATE <br /> t3 <br /> q �O <br /> �I9 <br /> DEPARTMENT E ONL <br /> Application Accepte B DateArea Employee ID#-Ri <br /> Final Inspection By Date 7KVI/9SPECIKL PERMIT-Approved by <br /> Character of Soil to Depth of Ft: S;✓t V L"-'dMn Pit/Sump Soil Character: <br /> COMMENTS S&/f '-elk-elk fa..��LG�af. �`�''� Sy,4 �a� ,...s.l,4a• - <br /> PE SC Received Check#/ Amount Permit/Code INFO B emitted Date Service Re uest# Invoice# Permit ID# <br /> t. Cil 0 Is <br /> 42-Ot ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />