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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 9$3-7697 FOR INSPECTIONS C EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I Id.A 0 E L>r�/~ CT• CITYMP I �—'�C-y l-T 3 Z)+ y <br /> CROSS STREET l� TEFF APN -;-c5-- 3��-0 3 PARCEL SZE I'L'I' 1 �-• <br /> OWNER NAME '��IS�fSI_ S{ PHONE (OQQ.1_ <br /> OWNER ADDRESS S NY✓)C CITY/STATERIP <br /> CONTRACTOR �-I�C Op'()e— V �"'�`� NmC'T� 1 PHONE �y <br /> CONTRACTOR ADDRESS 940� W �j- CITY/STATEMP ( ). C k `T�'4-0, <br /> LICENSE :].C-42 QC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> TPERC TEST #___I_ ! BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION C ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft 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 ft <br /> DISTANCE TO NEAREST WELLIt FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft A Y <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH R DEPTH R ► 1VI <br /> DISTANCE To NEAREST WELLft FOUNDATION ft PROPERTY LINE ft �® <br /> ❑ SUMPS WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH � O I QU/v J <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE RO NCO <br /> C3 SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DEPgRTT� <br /> DISTANCE TO NEAREST WELLft FOUNDATION ft PROPERTY LINE MFNT <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 /> ' INIMnOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 p, <br /> SIGNED p TITLE O N)✓LI 141W 1 DATE <br /> ft�'3—I <br /> Gr <br /> ART. <br /> 'NL/Y <br /> Application Accepted By p,� Date [� AreaA loyee ID# <br /> EC)�L PERM — <br /> Final Inspection By e� Date O V ❑ SPIT-4ypproved by <br /> Character of Soil to Depttfof 3 Ft: Pit/Sump Soil Character. <br /> COMMENTS <br /> PE SC Received hec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Bv Cash Remitted Service Request <br /> 7 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />