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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-KEFUNDABLE PERMIT <br />(209) 9953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROMDATE ISSL <br />C <br />JOB ADDRESS _ / ��aS E <br />�j /SCALL <br />-6P—A" D -r <br />1� <br />R•r> CITY/ZIP L0z'FE r V 9Q <br />/ S Z 7 4- <br />CROSSSTREET �!�, �Z/ <br />•�7� <br />J• <br />�d <br />/� <br />APN O�� 3Z©- �O Z�A-c <br />ARCEL SIZE <br />OWNER NAME ICUy �DN/J5���.'C.�1--a—IC�/�,�-�/l <br />/ r C \ <br />WI(k- JDAII )'4a� PHONE �^�3-� <br />�' ✓�( <br />OWNER ADDRESS _._3TV IIIJ <br />/ SNE > I •/ }y''2• <br />ii� CI S ATEIZIP (--O�I- CA <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />CONTRACTOR QV F- OA -Y— C3 <br />.'1 L-UCNV12�JNm�," i � \L PHONE 0%47 /y <br />CONTRACTOR ADDRESS �0 W • 0NY— ST• q CITY/STATE/ZJP I C r 1 _` 2' <br />LICENSE iC-42 , !C-36 OTHER NUMBER EXPIRATION <br />WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # ( BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: .. NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT DESTRUCTION <br />INSTALLATION WILL SERVE: FI RESIDENCE ! i COMMERCIAL t OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG CAPACITY 921 # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION it PROPERTY LINE It <br />❑ LIFTSTATION SIZE TYPE OF PUMP ❑ PKGTXPLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES _ LEACHING CHAMBERS # OF LINES <br />LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST WELL It FOUNDATION <br />ft PROPERTY LINE <br />It <br />❑ FILTER BED WIDTH ft LENGTH R <br />DEPTH <br />fl <br />DISTANCE TO NEAREST WELL It FOUNDATION <br />It PROPERTY LINE <br />ft <br />❑ MOUNDED WIDTH It LENGTH ft <br />DEPTH <br />ft Cj <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />I_.4 ` <br />❑ SUMPS WIDTH ft LENGTH It <br />DEPTH��,��'%i <br />DISTANCE TO NEAREST WELL It FOUNDATION <br />❑ DISPOSAL PONDS WIDTH It LENGTH ft <br />ft PROPERTY LINE /ftp 1 ` <br />DEPTHjflfl <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />❑ SEEPAGE PITS NUMBER WIDTH it <br />DEPTH <br />✓ 201D <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />L / <br />ft PROPERTY LINE •74. <br />I HEREBY CERTIFY THAT I HAVE PREPARED THISCATION AND EWORK WILL BE DONE ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINAN <br />S��p <br />LAWS AND RULES AND REGULATIONS OF SANIJOAQUIN <br />T gC/t/T _ <br />1' <br />Ii OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS PLEASE CALL (209) 953 7697 <br />4elvp <br />SIGNED TITLE e 0/V5VL,T11n.T <br />�'{ <br />DATE /7-10—If d <br />S,Mry- <br />Application Accepted By 'ISE / Date E Area Employee ID# W <br />Final Inspection By ^ 'X41/L, - Date l SPECIAL PERMIT - Approved by <br />Character of Soil to DeptK of 3 Ft: PitlSump Soil Character; <br />COMMENTS <br />PE <br />Code <br />SC <br />INFO <br />ReceivedeSW� <br />' <br />-Cash <br />Amount <br />Remitted <br />Date Permit/Invoice <br />erviceRequest # <br /># Permit ID# <br />i <br />i -1-,H- ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />