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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)466.3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS o 1 �-� rLD - CITYIZIP L-001 is-2-42— <br /> CROSS <br /> s-242—CROSS STREET1 ��- APN O O 1— (� PARCEL SIZE 1 -� Ac. p <br /> OWNER NAME A. Y-- TCK'-C'��A tj PHONE 7-1 O 391 <br /> / <br /> OWNER ADDRESS't SP�1'YI G1' CITYISTATEIZIP <br /> CONTRACTOR VI d C OR K- GcOtfW 12ar�1 Me MNN L PHONE 3W!C. <br /> ` 0 <br /> CONTRACTOR ADDRESS (), W /"T�" ST- CITY/STATEIZIP L'�7 1 C'h el l�C) <br /> LICENSE LIC-42 OC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # % BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION 0 REPAIRIADDITION L I ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT 0 DESTRUCTION <br /> INSTALLATION WILL SERVE: 0 RESIDENCE C] COMMERCIAL D 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 it FOUNDATION R PROPERTY LINE fl <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> O LEACH LINES U LEACHING CHAMBERS #OF LINES LENGTH OF LINES It <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE it <br /> ❑ FILTER BED WIDTH it LENGTH h DEPTH it <br /> DISTANCE TO NEAREST WELL it FOUNDATION h PROPERTY LINE it <br /> ❑ MOUNDED WIDTH it LENGTH It DEPTH it <br /> DISTANCE TO NEAREST WELL h FOUNDATION it PROPERTY LINE It <br /> ❑ SUMPS WIDTH it LENGTH it DEPTH it <br /> DISTANCE TO NEAREST WELL R FOUNDATION it PROPERTY LINE it <br /> ❑ DISPOSAL PONDS WIDTH It LENGTH it DEPTH It <br /> DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE it <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL it FOUNDATION R PROPERTY LINE it <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 L <br /> SIGNED TITLE CANS✓LTR NT DATE <br /> E FNT <br /> 15 ?0Z0 <br /> A N*r4L Y <br /> NT <br /> DEPARTMENT/USE NLY <br /> Application Accepted By Date Y! ZU Area t Employee ID# <br /> Final Inspection By Date— 1 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Fl: PIUSump Soil Character: <br /> COMMENTS <br /> PE SC Received Check# Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Remitted Service Request# <br /> `j�o(n,I(I <br /> 4201 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />