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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT BOO E MAW STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209}953-7897 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS +Z .-.O J I CITY21P N <br /> CROSS STREET F'.( 'Y i _APN � — �P7ARCEL SIZE <br /> �1�v o <br /> OWNER NAME 0/9Ct ti e*114 1^JS PHONE r3 a 9 O O m <br /> OWNER ADDRESS CITYISTATEILP <br /> CONTRACTOR A Y`1a"T'M i L/j o in So (� IV L PHONE -� j� C� �/' <br /> CONTRACTOR ADDRESS CO ! ! P�,t a.2. Rd� �C STATFJZtP ✓ .,!YL,t, �"'5�/C7 <br /> LICENSE '❑C42 ❑C-36 OTHER A NUMBER11571,ggEXPIRATIONDATIE a0lo <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y .O <br /> C1PERC TEST # _ BUILDING PERMR# AND USE APPLICATION# <br /> TYPE OF WORK: F NEW INSTALLATION ;K REPAIR1AODITION ❑ ENGINEER DESIGNED 1ALTERNATIVE <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 F Y $ i le r_ CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #CF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION_ ft PROPERTY LINE It <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 1*11 LEACH LINES ❑ LEACHING CHAMBERS lT> Eo 3 #OF LINES LENGTH OF LINES �1 o fl <br /> DISTANCE TO NEAREST WELL ft FOUNDATION .LO ft PROPERTY LINE <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> SUMPS WInTH (/ ft LENGTH %wjZ ft DEPTH !Q ft <br /> DISTANCE TO NEAREST WELL I_ft FOUNDATION ft PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R- 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 /> MIIN��!/I/�JM 24}�{QOUR VANC NOTICE REQUIRED FOR INSPECTIONS PLEAS,E[�CALL(209)953-7697 <br /> SIGNED �� iAth� .CJ� .� TITLE �O'17y14 el f�bu- DATE, _ <br /> i <br /> ` I <br /> I <br /> j I I <br /> a <br /> no <br /> c P <br /> N . <br /> � 7717 <br /> I <br /> EPARTMENT U E O <br /> Application Accepte Date Area Employee ID#,e��l <br /> Final Inspection B Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of Ft: Pit/Sump Soil Character: AL2�1.. <br /> COMMENTS OLI ) <br /> ' <br /> PE SC Received hec Amount Permit/ <br /> Code INFO B Cash emitted Date Service <br /> Request# invoice# Permit ID# <br /> i 6 <br /> I 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 10/N07 <br />