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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202.(209)4683420 <br /> NON-REFUNDABLE PERMIT \ CAUL(209)953-7697 FOR INSPECTIONS .�I EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS _ \ e i y —\f/I P.. \S itGt CITYMP -1y[:.��--.. ` �:'- �15-7 Z, f <br /> CROSS STREETS I' s�� ,r APN 19 1,,0- Z I- (PARCELS¢£ :,-�1 f1 A-, <br /> lg <br /> OWNERNAME + �' - 0.- PHONE 1 �1 ^ ' I <br /> OWNER ADDREAA ., CIW/STATFJZP <br /> CONTRACTOR 1 ,7' q1 PHONE ~`J s\0 <br /> CONTRACTOR ADDRESS 1 V-Z t. �,� CA^-.f -H ^ , CITY/STATERIP a ti l <br /> l / <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: It GEOORAPHICALINFORMATION: Coordinates X Y <br /> PERCTEST # BUILDING PERMIT# LAND USE APPLICATION 111 P '� �:•UJ_`!7 a> <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPIACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LNWO UNITS: NUMBER OF BEDROOM$: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TwE/MFG CAPACOY gal #OFCOMPARTMENTs <br /> ❑ GREASE TRAP TYFVMFG CAPACITY gal #OF COMPARTMENTS <br /> • DISTANCETONEAREST: WELL ft FOUNDATION it PROPERTY LINE it <br /> ❑ ❑FTSTATION SIZE TYPEOFPUMP O PKGTXPLANT ❑ SAND OILSEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES f: <br /> DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE If 1b <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEFT R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION If PROPERTY LINE It <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEFT ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION If PROPERTYLINE ft <br /> ❑ SUMPS WIDTH It LENGTH ft DEFTH It �. <br /> DISTANCE TO NEAREST WELL ft FWNDATION ft PROPERTY LINE ft - <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE It <br /> ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH ft Z <br /> DISTANCE TO NEAREST WELL ft FOUNDATIONft. 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(2m)953-7697 <br /> SIGNED �--I �,. �' '��.--„( �- TITLE N-�-- 1 DATE <br /> c <br /> • <br /> ! P <br /> EV <br /> E, UMF <br /> 4141 V <br /> H H I Ef W M <br /> I-"1 '_ � DEPARTMENT USE ON Y ' !/ G <br /> ADate i !/n T" <br /> �,r 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 ChecW,, Amount Date <br /> Code INPD '"Caeli Remltted Date a//eR/ ueet# Imdce# PermRID# <br /> 222 >Z I <br /> • <br /> 401 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 10MA7 <br />