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j ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAa TOACb l COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE <br /> 'PERRMIT �p ?CALL 209)9y�53-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> iv <br /> JOB ADDRESS 7 J 5 t-/l l A-S 290 !� - <br /> Q CITYIZIP f- f Z,,& � /ge p 5 f <br /> CROSS STREET l�ln rr�f2s n APN ( 3 -" ��—•S� PARCEL SEM r/- yb > <br /> OWNERNAMEpLI�I�Y'fPHONE 7/L •• %���` — <br /> OWNER ADDRESS n S'/Ml 4!f q� �• CITY/STATEMP n y <br /> CONTRACTOR 1.�(�- 1fLnU M,�f N"G�7�J _PHONE 271 <br /> i� J����� 2 <br /> CONTRACTOR ADDRESS I�-G• L! 1711/ CITY/STATErZIP <br /> LICENSE QC-42 Pe.46 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATIDN: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION X REPAWADDITION ❑ ENGINEER DESIGNED IALTERttaTnrE <br /> ❑ REPLACEMENT 0 OUT-OFSERVICE SEPTIC SYSTEM C 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 /> [3 GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS I` <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE it <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENC <br /> EYSTEM) <br /> yr LEACH LINES ❑ LEACHING CHAMBERS #OF LINES /.LE, <br /> GTH OF LINE e3 ft L� <br /> DISTANCE TO NEAREST WELLt&© ft FOUNDATION PROPERTY ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH tt <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH k LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ~ <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It 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 /> NI R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE �i lrtyt � DATE <br /> I <br /> NT <br /> R' <br /> f I <br /> I 1 <br /> ED <br /> ZUSIO <br /> N COUNT <br /> i 7 S N O EI,;'AL. <br /> l T1 D pHTMEN <br /> i� D- P.ARTM.E.N.T._S:E. NLS_ <br /> Application Accepted By Date O Area Employee ID# <br /> n81 Inspection ey 3 _ <br /> Data 1 0 SPECIAL PERMIT-Approved by <br /> Fi �. _ <br /> of Soil to D th of 3 Ft: P' u P Soil Character: <br /> C. MMENTS AJSLJ L-0Or- P C- D <br /> pE SC Received a Amount Date Permiti Involce# Permit ID# <br /> Service R nest# <br /> 'Code INFO B Cash Remitted <br /> o !t5 !1! 2-30.0-0 <br /> ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> a2-01 - <br /> i 812MS � <br /> ^ 'r <br />