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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT !� CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS I o 2.To W..��C.17 L-DI"CS? 02-n • CITr21P 5-F3 Ck..TD7J 9-S2-1 7- }� W <br /> CROSS STREET Ilk L-L,E/y APN 1 Zy- y 30 -P / PARCEL SIZE 1 •`r tj <br /> -rte 5'j3--9_71'j t7 <br /> OWNER NAME (Zd avL- C'O's .'�"G IZ� PHONE ' 13-S7Z.-I <br /> OWNER ADDRESS s �pG�' CITY/STATE/ZIP <br /> CONTRACTOR ,�I' PHONE .3(P9_O`'3_1S_ (, <br /> CONTRACTOR ADDRESS 0 1 W' O A K' S-r' CITY/STATE/ZIP LD✓J 1 -i�� <br /> LICENSE QC-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # 1 BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAWADornON ❑ 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 It <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 <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft �® <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fte� <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ;F <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE_ ✓Od i. O�D <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH �/� C <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE_ /-/y NTq�ry <br /> ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH T/yEN <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft T <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,2.POUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE LdrwSyL-'T OV— f DATE <br /> DEPARTMENT PSE ONLY <br /> Application Accepted By Date 'Z 2OZb Area Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PESC Received Check# Amount Date PermiU Invoice# Permit ID# <br /> Code INFO Remitted �nService Re uest# <br />