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)2 <br /> 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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS CITVIDP <br /> CROSS STREET A/t/ /,.� APN �F�J/' tJwf'' PARCEL SIZE _ a <br /> OWNER NAME -Y C-�a�rL PHONE l�j•CIG�(-I TT <br /> OWNER ADDRESS CITYISTATE/ZIP <br /> CONTRACTOR /_-�`l/J1 !/IJLL/�" S �L PHONE ZL'1•�d�7 <br /> CONTRACTOR ADDRESS ��'•� L�/s.n- /J/L _CmISTATE/LP <br /> LICENSE Q k-4;2 QC-36 OTHER NUMBER V5-9z,"71 5--EXPIRATION DATE ��'"3/•/Z <br /> WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> [-n PERC TEST # BUILDING PERMIT N LAND USE APPLICATION# <br /> TYPE OF WORK: n NEW INSTALLATION REPAIR/ADDITION O ENGINEER DESIGNED IALTERNATNE <br /> Li REPLACEMENT i! OUT-OF-SERVICE SEPTIC SYSTEM o DESTRUCTION <br /> INSTALLATION WILL SERVE: 1� RESIDENCE I] COMMERCIAL ❑ OTHER <br /> NUMBER OF LMNG UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> O SEPTIC TANK TYPE/MFG_may T CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL it FOUNDATION it PROPERTY LINE it <br /> O LIFTSTATION SIZE TYPE OF PUMP _- ❑ PKGTXPLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> N LEACH LINES 11 LEACHING CHAMBERS #OF LINES LENGTH OF LINES —ft <br /> DISTANCE TO NEAREST WELL SU R FOUNDATION SD R PROPERTY LINE I S it <br /> ❑ FILTER BED WIDTH it LENGTH It DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE it <br /> ❑ MOUNDED WIDTH it LENGTH it DEPTH It <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE it <br /> ❑ SUMPS WIDTH ft LENGTH it DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> O DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE ft <br /> 1 WIDTH 3 ft DEPTH �C ft <br /> OL SEEPAGE PITS NUMBER I <br /> DISTANCE TO NEAREST WELL ILS It FOUNDATION // _ft PROPERTY LINE--S ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARESD THIS <br /> SLAPPUCATION AND AWS AND RULES THEND WORK WILL <br /> B OF SAN N ALCORAQUIN COU TM WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE fes.L� �.. DATE fr1 01 <br /> Y <br /> s w <br /> ---------IE <br /> •1 <br /> I <br /> O' <br /> PART MEVT NLY [ <br /> Date fi <br /> Area Employee ID# <br /> Application Ac <br /> Final Inspection t Date ❑ SPECIAL PERMIT-Approved by <br /> PIUSump Soil Character: <br /> Character of Soil to pth of 3 Fl: <br /> COMMENTS <br /> - <br /> PE SC Received Ch Amount Permit/Date invoke i Permit Il>m <br /> Code INFO B <br /> as Remitted Service Request# <br /> � <br /> ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 42-01 <br /> 9/21/10 <br />