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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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 'Z ,5 F•-c-u-t, cr,me y e CITYY0P 'lS-I" C'I<4'-0t j G?S 2 d fa, � <br /> CROSS STREET e PC.,1. •0 APN � (��l ZJ U Z PARCEL SIZE g <br /> OWNER NAME SG�CrKU� I/`LL/e!/` / PHONE L O r�• 42t" �7 yc <br /> OWNER ADDRESS IT,�/ CITY/STATE21P q �J�•QG�"/�/L i/ --•7 / <br /> CONTRACTOR �'jl(T�Nom-! V!s r/-/< y {(/���'YJp l• •�Jf1 PHONE /vJ <br /> CONTRACTOR ADDRESS Jl QU �U V'• f• "•"�'/�')J� CITYISTATEIZIP 17•O'CL'��CU <br /> LICENSE QC-42 QC-36 OTHER C-�� NUMBER `ter �5 EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE CATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION 0 REPAIRIADDITION C E GINEER DES[ NED IALTERNAT E <br /> G REPLACEMENT 0 OUT-OF-SERVICE SEPTIC SYS M D TRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL 11_0_14R <br /> NUMBER OF LNG UNITS: NUMBER OF BEDROOMS: NUMBELIVINGR OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY Jai #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ LIFTSTATION SIZE TYPE OF PUMP ❑ PKGTXPLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY UNE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH It LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft 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 /> NIMU ONOTICE REQUIRED FOR INSPECTIONS-PLLEASE CALL 209 953-7697 <br /> L,-� <br /> 1� <br /> SIGNED // J <br /> Y .[''.'T <br /> III EPARTMEN TIIJ S EIO N L Y I <br /> Application Accepted B Date Area Employee ID# <br /> Final Inspection By Date ?_— ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to pth of 3 Ft: P1 Sump Soil Character: <br /> COMMENTS Z <br /> Iz <br /> PE SC Received eck Amount Data Permit/ Invoice# Permit ID# <br /> Code INFO B ash Remitted Service Rewest# <br /> r � t <br /> ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 42-01 <br /> W21110 <br />