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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 YEAR FROM DATE ISSUED <br /> I « I sir{ tii.✓.-f..,/ cc CrrrfZIp IS%,A L-0,./ '7 =Z c' y <br /> JOB ADDRESS ICd�- l-Z. � t,.��— y <br /> m <br /> wl L,l i ( -G:5"..G^.t��_ PARCEL SIZE <br /> GROSS STREET / - APN o <br /> j �d1 c �G,1 dr..nJ rul�F.�\/ f-G.G PHONE -Z-,7)' �rYJ� a j~I� <br /> OWNER NAME _ 7ri <br /> OWNERADDRESS L,`7{rc-o F,)A-'C le tCo/3 t7 CITYISTATERIP f'r�12 x'11„/G �v�t.f C6)• 3��' <br /> CONTRACTOR 1 L Ci h.!' /��`J rt..17 t`t� PHONE �/`• <br /> CONTRACTOR ADDRESS .G�_ I'S v X 1 �L"��✓ CrrYlSTATEIZIP - {, 1✓ <br /> LICENSE ❑C-42 11 C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> [2' PERC TEST # BUILDING PERMIT# LAND USE APPLICATION#'i' <br /> I TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED lALTERNATNE <br /> L ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMS£R OF EMPLOYEES: <br /> 0 SEPTIC TANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> O GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> F1 DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 0 LIFT STATION SIZE TYPE OF PUMP 13 PKG TX PLANT 0 SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 0 LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft t <br /> r O FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> f 1 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE - -ft <br /> .j O MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE - ft <br /> Cl SUMPS WIDTH ft LENGTH ft DEPTH ft ^ <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft \. <br /> 13 DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH it <br /> DISTANCE 70 NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> O SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 /> l INIMUM 24 R ADVANCE NOTICE REQUIRED FOR INSPE7ONS-PLEASE CALL(204)963.7697 1,,1 <br /> SIGNED /f, .V U TITLE �'c'Ji � /.! DATE <br /> F., <br /> I <br /> I-. IL I <br /> + -- <br /> I •"iii -.f fp DEPARTMENT SE NLYLL. <br /> II Application Accepted By ��"'""� — Date i; !f 1(` Area Employee ID# '1 r .�� <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by f <br /> Character of Soil to Depth of 3 Ft:. Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC ReoorwAmount PermR/ <br /> Data Invoice# Permit Iii <br /> : F Code INFO Cash Remitted ,ServleeR oast# <br /> A/ <br /> IAg <br /> 1 <br /> - 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 1014107 <br />