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f <br />- ­ <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />600 E MAIN STREET - STOCKTON CA 95202 - (209) 468.3420 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />NON-REFUNDABLE PERMITS <br />CA( 09) 953 7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />1�131q <br />CITY/ZIP ✓\mt`l� �..t��'� <br />y <br />JOB ADDRESS <br />`� N't" <br />�a <br />APN �r6 S^�la�—n/10 <br />CROSSSTREET >/'TJf'ffr4 <br />_ gyp/PARCEL JSZE <br />zu <br />Q <br />KI g Slt PHONE <br />fA <br />OWNERNAME <br />L`• <br />OWNER ADDRESS <br />�J \�✓(- CITISTATElZIP <br />CONTRACTOR <br />PHONE <br />�M l�'A- CITYISTATE/ZIP <br />CONTRACTOR ADDRESS <br />LICENSE :]C-42 ❑C-36 <br />OTHER NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # <br />J] BUILDING PERMIT # _ LAND USE APPLICATION # <br />TYPE OF WORK: <br />❑ NEW INSTALLATION '7 REPAIRIADDmON ❑ ENGINEER DESIGNED !ALTERNATIVE <br />❑ REPLACEMENT C DESTRUCTION <br />INSTALLATION WILL SERVE: ' RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPEIMFG _ CAPACITY _ gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG CAPACITY _, gal #OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL it FOUNDATION_— ft PROPERTY LINE <br />ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />I <br />❑ LEACH LINES <br />L LEACHING CHAMBERS # OF LINES LENGTH OF LINES <br />it <br />DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE <br />ft <br />❑ FILTER BED <br />WIDTH ft LENGTH_ ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />It <br />❑ MOUNDED <br />WIDTH _ft LENGTH it DEPTH <br />It <br />DISTANCE TO NEAREST WELL ft FOUNDATION — ft PROPERTY LINE <br />ft <br />❑ SUMPS <br />WIDTH ft LENGTH -ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE <br />it <br />t <br />❑ DISPOSAL PONDS WIDTH it LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />y� <br />h <br />❑ SEEPAGE PITS <br />NUMBER WIDTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE <br />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 />MINIMUM ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (2D9) 953.7697 <br />SIGNEDr;�� <br />TITLE DATE <br />Application Accepted <br />Final Inspection By 5J <br />Character of Sol[ to Depth of 3 Ft: <br />COMMENTS,II d.0 -Q <br />DEPARTMENT U E Y <br />Date _.._ Area _ Employee ID <br />Date -1 SPECIAL PERMIT - Approved by. <br />Pit/Sump Soil Character: <br />;((' �Artf- - /'G f�1' Citlt�'LrvrGiw713TiE b sz�c�Gitiri� Tr�%1a`tiuG <br />�" �3Cll�l /-fa'7� � /-dT��S�z,I i,4: 'ca� F� A-7�.odkf-e�L �11c,EY�F'►� Z`-2u�__�*�c�z<n7 <br />PE SC Received Ch Amount Date Permit Invoice Permit <br />Code INFO B ash Remitted Service Request # <br />zit N o <br />2 /;yu/,&�g T� AV- 1�'*77,/O-3 4"a e- 1?a001ttz: i.>r�f it �f .gym )( Ga�1Ni�r t7 Wr�t� J <br />ZZ1 / < Z�� ONSRE WASTEWATER TRTMNT SYSTEM PERMIT <br />10/4/07 <br />ra <br />