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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 96202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS '-' Pi CITY/ZIP / u' <br /> CROSS STREET � ��J��Vp�(��/ /- - -J—p APN ""��0 ��� PARCEL SIZE <br /> OWNER NAME sr" �(�//(� ,w/"`��`"/ PHONE <br /> OWNERADDRESS A_/J5&e;9 'OV C� CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C]C-42 4C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# O LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: I RESIDENCE ❑ COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTICTANK TYPEIMFG CAPACITY gal #OFCOMPARTMENTS Z <br /> ❑ GREASE TRAP TYPE/MFGCAPACITY gal #OF COMPARTMENTS <br /> DISTANCETO NEAREST: WELL 1��..�� ..t-- It FOUNDATION It PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPEOFPUMP ❑ PKGTXPLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES Z LENGTH OF LINES <br /> DISTANCE TO NEAREST WELL �'r ft FOUNDATION It PROPERTY LINE It <br /> ❑ FILTER BED WIDTH ft LENGTH it DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY UNE it <br /> ❑ DISPOSALPONDS WIDTH ft LENGTH ft DEPTH it <br /> �1 DISTANCE TO NEAREST WELL ft FOUNDATION�ft PROPERTY LINE ft <br /> f� SEEPAGEPITS NUMBER *2 ' WIDTH & ' -1 " DEPTH ft <br /> !� DISTANCE To NEAREST WELL _ft FOUNDATION It 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 /> MIN UM 24 HOU ADVANCE NOT/C REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 (� <br /> SIGNED A TITLE DATE . • 7 �� <br /> b <br /> 5 NJ .. Ui,T <br /> D PARTMENT SE NLY HEAL:"L�` RNT T <br /> Application Accepted B Date Z Area Employee ID#s%!� - -F----f <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PittSump Soil Character: <br /> COMMENTSv ,6[�F � � - <br /> PE SC Received C Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Remitted Service Request# <br /> r <br /> 42-01 <br /> ONSITE WAS�EWATER TRTMNT SYSTEM PERMIT <br /> 9/21/10 <br />