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ONSITE WA -EWATER TREATMENT SY: 'EM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E Mi IN STREET-STOCKTON CA 95202-(209)468.3420 <br /> NON-REFUNDABLE tPERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOS ADDRESS 110 tJ S- CITY/Zip a- LA <br /> CROSS STREET APN �U��?i����jl PARI Ej iaE), b.� 9 <br /> f <br /> 0 <br /> OWNER NAME 6;14 V lr�a � � 1 I, PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR Q PHONE Z/2-3-7OI <br /> CONTRACTOR ADDRESS CITWSTATE21PV__�� ! <br /> LICENSE 4C-42 QG36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y '/t <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: C NEW INSTALLATION = REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER I <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> O SEPTICTANK TYPE/MFG CAPACITY gal #OFCOMPARTMENTS <br /> O GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION it PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> O LEACH LINES J LEACHING CHAMBERS #OF LINES LENGTH OF LINES it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it <br /> O FILTER BED WIDTH it LENGTH it DEPTH it <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE it <br /> O MOUNDED WIDTH it LENGTH it DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE it <br /> O SUMPS WIDTH ft LENGTH it DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE It <br /> O DISPOSAL PONDS WIDTH It LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE it <br /> O SEEPAGE PITS NUMBER WIDTH it DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <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(209)953.7697 <br /> SIGNED TITLE DATE 7- S- a <br /> it <br /> Jp . <br /> O M <br /> N <br /> ARTMENT 31210 -Y_ <br /> Application Acc pted B Date Area Employee ID# _�//// �I� <br /> Final Inspection By l[y ,� _ � Date o ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to D pth of 3FI( Py' Sump Soil er: <br /> COMMENTS i d ✓c1� 9r5 <br /> PE SC Received Chec Amount Permit/ <br /> Code INFO B Cash emitted Date Service Re uest#Permit/ Invoice# Permit ID# <br /> ZZ z l <br /> 42201 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />