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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 <br /> 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I W 5 0 w . LOL r�jQ�l j�S CA)rA`� CITY21P � � -13-3134 <br /> y <br /> =a <br /> CROSS STREET T 1 1 f•l pis c t'M /� /� !� �j APN ZL !/']-�/��0,`//,/�'7I��J��� P/A-RCEL SIZE <br /> OWNER NAME ./P,^jN14 } �•� 1_"'I!� f E.1`--JC I 7Z10nVA-/0J,- 3- "HONE <br /> I <br /> OWNER ADDRESS Sit V" CITY/STATE/ZIP <br /> CONTRACTOR LI V t 'O A K- G-(r O E ►'"l EN'Tl`�L PHONE 3(0'1 y 3-)'5 <br /> CONTRACTOR ADDRESS "r D �� -• CITY/STATEP LODI CSR- �SC7 <br /> 21 <br /> LICENSE QC-42 OC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # I BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDrnON ❑ 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 /> ❑ 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 WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELLft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELLft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <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 /> INIMUM 24 R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953.7697 <br /> SIGNED TITLEG6/uS✓L i ft n,!i DATE /I -yZ- 9 <br /> i <br /> f��vr <br /> I ' ' ► - 2 pf9 <br /> 1. <br /> V OAC TY <br /> MFNT <br /> w / <br /> U t <br /> I <br /> eDatEPARTMENT U E Oyg <br /> Application Accepted By e. AreakIALIE1 <br /> Employee IO# A* <br /> Final Inspection By Date ❑ SPEIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> s� <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO B miffed Date Service Re u`estt# Invoice# Permit ID# <br /> r 1 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />