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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 9553-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1 S lZ0 V Ty f CITYIZIP <br /> Oct 0!fo-o3 -o&.a-o p a <br /> Owoae S�raeer Qv�y Goe-FADN C'i!—01 I PARCEL SIZE <br /> OWNER NAME PAVL-1 C-P(t-OSS-O PHONE <br /> OWNER ADDRESS 2Q Tqq JAC'- TDNC' 1 CRYISTATE/ZIP Ghl�r, cA 9S�3Z <br /> y _ I <br /> CONTRACTOR L-I V� 0�- &t;-,Z7 IZ6 N �VK 15A1► PHONE <br /> CONTRACTOR ADDRESS <br /> T07 �- 0� lwr. CITYISTATFJZP <br /> LICENSE ,]C-42 ',�C-W OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> )C PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: L NEW INSTALLATION REPmR/ADDinoN ENGINEER DESIGNED/ALTERNATIVE <br /> L. REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: �N�UMBEREMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION it PROPERTY LINE ft I <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 _R FOUNDATION ft PROPERTY LINE ft { <br /> ❑ FILTER BED WIDTH it LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft I <br /> DISTANCE TO NEAREST WELL _ft FOUNDATION ft PROPERTY LINE ft `I <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH It ! <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft I <br /> ❑ DISPOSAL PONDS WIDTH It LENGTH it DEPTH ft j <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it <br /> t <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 /> HO <br /> i IAC^IiINII v`4 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)951-7697 <br /> SIGNED TITLE 'r <br /> GNL <br /> OSVrrt NT DATE ��00 <br /> ri <br /> � FNr <br /> o2014 <br /> c,� <br /> F AIRTMlNrY <br /> U - <br /> 11ww ww ���7 <br /> DEPARTMENT USE ONLY / — <br /> Application Accepted By •"1 ' A. W''ter Date "f b Area" Employee ID# <br /> Final Inspection By_ Date .` SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Ch Amount Date PermlU Invoice# Permit ID# <br /> Code INFO B Remitted Service Re uest# <br /> 4''al 3 Zz- 0 6 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 1014107 <br />