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1414,311 t VVAA 1 tVVA 1 CK I KtA 1 MtN I SYJ 1 tM YtKMI I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)4684620 <br /> NON-REFUNDABLE PERMIT �j,/�� CALL(2009))953-7697 FOR INSPECTIONS �y��l,E'XPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADORESS 110'�1'T0 p%p ��. 1'J&Abw IY �fF CnYZP >1ULT"� -/S�J V, <br /> CROSS STREET W�E-A-Lx o APN 1 L4 3—Z SO— 17— <br /> PARCELS6E O'-!-(-T{�• g <br /> OWNER NAME M1IdeG(.Y{ PHONE 7-71-9131 <br /> . OWNERADDRESa SfttM6 I CRY)STATEZP -T <br /> CONTRACTOR LIVE OA1c 6C0ENV/2brJMeATA'L PHONE 310'I-O3 <br /> CONTRACTOR ADDRESS 4D-+ yJ' OikK. 57I". CITYISTATEZP <br /> LICENSE QC.42 QC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICALINFORMATON: Coordinates X Y <br /> PERCTEST # I BUILDINGPERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAUVADOITION ❑ ENGINEERDESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCUU. ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <br /> ❑ GREASETRAP Ty,E FG CAPACITY gal #OFCOMPARTMENTS <br /> DISTANCETONEAREST: WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP O PKGTXPLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTHOFLINEs ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE It <br /> ❑ FILTER BED WIoTN ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH It LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTYLINE R <br /> ❑ SUMPS WIDTH It LENGTH It DEPTH It <br /> DISTANCETONEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH it LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH It <br /> • DISTANCETONEAREST WELL It FOUNDATION ft PROPERTY LINE ft <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 RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> ! A�,(�MINI/RtJi/M'yp4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED I/�-�=F/V� TITLE CQN4WLIflNT DATE `X-IZ-Ik <br /> I ' <br /> �oaw 1018 <br /> MgI,T <br /> Tl <br /> DEPARTMENT USE ONLY <br /> Application ACeepted B Date /3 — Area Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-AppTovetl by <br /> Character of Soil to Depth of 3 FC PINSump Soil Character. <br /> COMMENTS <br /> PE I SC I Received CheCW I Amount <br /> Code INFO B ash Remitted Date Service Re uest# Invoice# Panntt lD# <br /> aa?- 13 2 i 2131 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />