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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 <br /> p PERMIT '1p� �G rCALLL 209 953-7697 FOR INSPECTIONS p EXPIRES'I YEAR FROM DATE ISSUED <br /> JOB ADDRESS 4O 4g- r /1 N)ES 1 „r>• CITY/ZIP '+�1 K4 Po 11-7,2-0 v' <br /> O C `y <br /> CROSS STREET �r�N Dy W I NG. APN 0( "t` y ZU- PARCEL SIZE 0 AC o <br /> OWNER NAME /�'D E� D SAN LJ� ` PHONE <br /> (� y <br /> OWNER ADDRESS/ 1174 CK-Eti K-Sl D �M/ , CITY/STATE/ZIP � GA /SlD3 Z <br /> W <br /> CONTRACTOR ✓C- 0 A-W- CCC-N�I��ZrV^N' NTr4 L m E � PHONE 3(.9 -o3�-S <br /> CONTRACTOR ADDRESS TD� W • 0Ay S I • CITY/STATE/ZIP L.-OD <br /> LICENSE I,C-42 EC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> )( PERC TEST #____L_ I F§UILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: L NEW INSTALLATION REPAIR/ADDITION 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 /> ❑ 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 LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE To NEAREST WELL It 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 /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE To NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT 1 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 /> MINIMU HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE 661-5 VL-1 q)t--r DATE Z _ / <br /> yMENT <br /> CEIVED <br /> g 2019 <br /> A <br /> SAWIOAQUIN <br /> TH DEPARTMENT <br /> DEPARTMENTU E ONL I/ pn <br /> Application Accept4By & Date /J Area Employee ID#St.k , LY <br /> Final Inspection By Date _I SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PKIS6p Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Cash Remitte Service Request <br /> 42-Ot ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />