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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAW STREET-STOCKTON CA 95202-(209)468-Wo <br /> NON-REFUNDABLE PERMIT CALL 209 953.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JoBADDRM I0-3-7-,+ S. LAWS-EN1GC (LD- ' CrYZP ESCA'L-Qnj fr n� a <br /> CROSS STREET AZTN-V�L APN 7-z4)✓nf -04D `0 T PARCEL S¢E Z'�F3 Ac <br /> • OWNER NAME G+1'>ZISTiNR n^•I�s/ND PHONE ('+'9 4S'Z2. P <br /> OWNERADDRESS Z34(0 JESS/L,.-An� C-IQ- CITY/STATE21P ESCR(LO�N CA CI5321 G <br /> CONTRACTOR 1-IJLT OAIL Cs EOE.�1VY12oTJW�Eui'ft L PHONE <br /> CONTRACTORADDRESS 40-4 W• L)AIL ST. CITY/STATE/ZIP 'IS G`fc7 <br /> LICENSE CIC-42 4036 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICALINFORMATON: COOrdinateS X Y <br /> J( PERC TEST # 1 BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION, ❑ ENGINEER DESIGNEDIALTERNATIVE <br /> D REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LMNG UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPEMIFG CAPACITY gal #OFCOMPARTMENTS <br /> ❑ GREASETRAP TYPEIMFG CAPACRY gal #OFCOMPARTMENTB <br /> DISTmoETONEAREST: WELL IT FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFTSTATION SIZE TYPE OF PUMP ❑ PKGTXPLANT ❑ SAND OILSEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTHOFLINEs ft <br /> DIsTANCETONEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH R LENGTH It DEPTH ft <br /> DISTANCETONEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIOTH It LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYUNE ft <br /> (3 SUMPS WIDTH ft LENGTH IT DEPTH It <br /> DISTANCETONEAREST WELL ft FOUNDATION It PROPERTY LINE IT <br /> ❑ DISPOSAL PONDS MOTH ft LENGTH ft DEFTH ft <br /> DISTANCE TO NEAREST WELLft FOUNDATION It PROPERTY LINE ft <br /> • ❑ SEEPAGE PITS NURSER WIDTH ft DEFTH ft <br /> DISTANCETONEAREST WELL R 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 /> INIMUM�22PV)UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS.PLEASE CALL(209)953.7697 G <br /> SIGNED //i( TITLE GONr VLI 1t N'T DATE <br /> Pqy4f, <br /> QUA <br /> I E >MN <br /> I <br /> EPARTMENT USE ON--Y,,AA)Q n <br /> Application Accepted By Date 1 1G[/1 1 Area_ Employee IO# �g�5 <br /> Finallnspection Bk V v Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 FC PR/Sump Soil Character. <br /> COMMENTS <br /> • <br /> PE SC Received hee Amount Date, Permit/ Invoice# Penritlo# <br /> Code INFO sh Re itkd ServlceR uest# <br /> -2 - <br /> 42-0t ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />