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vrw,I` rvri.7 I cvvm I CK 1 K=A I IVItN I YJ I tM PtKMl L <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL <br /> �+ / OCAL/1Ln 209 953-776697 FOR INSPECTIONS O[� EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Z R94+ 7• C— 919 r r 1 A 1�,� 9rJ CITY21P <br /> �yG _ H <br /> CROSS STREET I'-I N� APN Z `6 '-Dec)'oq- PARCELart <br /> SIZE p� r1 t <br /> OWNER NAME_._W D� I�Ca• (�r\nI��N Vv►• a��E. � PHONE <br /> �y-+0 <br /> OWNER ADDRESS 'i-+Ol pE,� /`ALJ CITY/STATE/ZIP _TRIM Vf CA 'qS 30 N <br /> CONTRACTOR L1 V 6 OPW— 6-e0C QV I P-D/JPn9./V i A L_ PHONE <br /> CONTRACTOR ADDRESS 40-� t/1.). 0PK r-. 19 7. CITYISTATEIZIP LZI✓I CA JY-21('t-0 <br /> LICENSE �C-42 ❑,C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> X PERC TEST # —� BUILDING PERMIT# LAND USE APPLICATION# /k -1 -1 2 <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT 0 DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPEIMFG CAPACITY gal #OFCOMPARTMENTS <br /> ❑ 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 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 ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELLft 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 /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft 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 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 /> MINI 4 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE G�Sy�•�A�wDATE `24P-1 <br /> Cc- LU <br /> eh <br /> DEPARTMEN EON ///�/ <br /> Application Accepted By Date Area Employee ID#'dzM "� <br /> Final Inspection By Date ED SPE <br /> IAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PiVSump Soil Character: <br /> COMMENTS <br /> AA4Yd Che Amount Permit/ <br /> Ca emitte Date Service Re uest# Invoice# Permit ID# <br /> (SS 't G <br /> 42-0, <br /> ^� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />