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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I GO r0 S• PANE iZ S D to PPrS S ¢D• CITY/ZIF 1/�f�-C,'4 <br /> CROSS STREET SOD APN !-0 !-10-D-Z4- PARCEL S¢E �S{A-c V , <br /> 0 <br /> OWNER NAME .SI:T A-W L-C A I N C. PHONE III ZS-LSO- SS11 0 a <br /> v -7_ mil <br /> OWNER ADDRESS P. D� �a/� � �� l CRY/STATE/ZIP <br /> CONTRACTOR 1-4;J E O,^.AIL GE-0 EEjIJmiE7ti1T A L- PHONE Z �I - 3(V'l-03�•� <br /> CONTRACTOR ADDRESS 'r'c�� W' Or\� ST• CIN/STATE/ZP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # I BUILDING PERMIT#� LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ 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 TYPE/MFG 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 /> ❑ LIFTSTATION SIZE TYPE OF PUMP ❑ PKGTXPLANT ❑ 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 ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It <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 It <br /> ❑ SUMPS WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELLIt FOUNDATION ft PROPERTY LINE R <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 /> ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953.7697 q <br /> SIGNED TITLE � `'�I DATEPA <br /> 9*0 <br /> - Np2 �p�9 <br /> / \ �OgQU�N <br /> IN <br /> \V \ <br /> l <br /> PARTMENT USE ONLY i f S�s ✓v <br /> Application Accepted By r Date 1 Z, U)I� Area Employee ID# jYJ <br /> Final Inspection By / Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil CharacCharacter.COMMENTS�4''�2 t V,of <br /> tl tri y r,;k2 r sEtt t.l-ol V,'-r-- F:;'Ln1i L! Liv 4> ' <br /> PE SC Received Chec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO r Remitted Service Re ues <br /> 41 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />