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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT y�CALL 2009)9}53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 6 JD W• vLr 1"� CIN/ZIP C-01> 2— <br /> CROSS <br /> CROSS STREET APIN PARCEL SIZE <br /> OWNER NAME AMAy <br /> PHONE 10 e> <br /> y <br /> OWNER ADDRESS CIN/STATEIZIP <br /> CONTRACTOR LI flyrQPly- G�of'N%l 117O^CJ M E Nt VN L PHONE 3 /— <br /> CONTRACTOR ADDRESS TD-) W• oft— •.T- CIN/STATE/ZIP L��l CA <br /> LICENSE JC-42 C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST #____I _ BUILDING PERMIT# _ LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION f i REPAIRIADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT DESTRUCTION <br /> INSTALLATION WILL SERVE: I I RESIDENCE COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL It 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 It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE It <br /> ❑ SUMPS WIDTH ft LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION It 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 /> INIMUM 2 R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 c <br /> SIGNED /j✓l TITLE Ca V S✓L-r ANT DATE <br /> n <br /> HENT <br /> EIVED <br /> 032019 <br /> AQUIN COUNTY <br /> - RONMENTAL <br /> HEP Lff 11 DEPARTMENT <br /> DEPARTMENT USJE ONLY <br /> Application Accepted By Date Area �� Employee ID# �r <br /> Final Inspection ByOtg Date SPE L PERMIT-Approved by <br /> Character of Soil to ep h of 3 Ft PiUS mp Soil Character: <br /> COMMENTS ��.TG } L(, 14E R li kt <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Ca h Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />