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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> VAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 96202-(209)468-3420 <br /> i <br /> NON-REFUNDABLE PERMIT: CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS in/ 156 W. VIA 1 1 a Cob- goCITYfzp.f1 4'-t G A � <br /> i CROSS STREET MOu�1 1 n iTtr SG pG� ?��l 1 y '�'- PARCEL$12E1p <br /> e <br /> �M /� 0 <br /> OWNERNAME V r 1 U"C" 01 j,w-C/ PHONE <br /> I <br /> I OWNER ADDRESS n'hAL_ CITY/STATE/LP <br /> CONTRACTORaC,(L�ITV PHONE ' ��� <br /> CONTRACTOR ADDRESS P-0 &)c & �n CITYJSTATEIZIP rnca`a,4,4_ 25-3M <br /> LICENSE I-C42 f]C-36 OTHER NUMBER tP gs-slq EXPIRATION DATE tS 1 !� <br /> kWATER TABLE DEPTH: ^' tl GEOGRAPHICAL INFORMATION Coordinates X Y 1` <br /> ❑ PERC TEST # BUILDING PERMIT# O ff2k..3 LAND USE APPLICATION# <br /> TYPE OF WORK: a3' NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE C <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION 4 <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL , OTHER atlt A e P <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG �-I^L. CAPACITY 12*A gal #OFCOMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> I ,y <br /> DISTANCE TO NEAREST: WELL 10ft FOUNDATION ft PROPERTY LINE 1M� ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> I ' l <br /> V/LEACH LINES P-C&CHING CHAMBERS d1I #OF LINES _ LENGTH OF LINES Std k <br /> DISTANCE TO NEAREST WELL j Ill FOUNDATION 10 ft PROPERTY LINE !A61 it I <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 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS MOTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTYLINE ft <br /> II 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209).953- 97 <br /> SIGNEDTITLE CEiAeGt16r DATE <br /> I <br /> T CV <br /> xh <br /> I` c <br /> or <br /> /! <br /> DEPAILTMENTO E <br /> Application Accepted By ato J Area Employee ID# 62&ra <br /> Final Inspection B Date O ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to D pth of 3 Ft: VSump Soil Character: <br /> COMMENTS <br /> PE SC Reeslved ec Amount Date Permit/ Invoice# Permit ID# <br /> t Code INFO B ash Remitted Service Request# <br /> 4 . _117 VZrX3'3. <br /> 42-01 _.,. JNSfTE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 9121110 �``-' <br />