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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 R CALL 2179)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS \��A17i i111% Ti � SI CITYIZIP c-, � <br /> CROSS STREET APN � t/ PARCEL SIZE %' ! l l� <br /> OWNER NAME �] _ �- �V\C5 \© �] __ PHONE C?dc\- <br /> OWNER ADDRESS \ 1 CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE EC-42 ©C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> © PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIRIADDITION LJ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: D RESIDENCE 0 COMMERCIAL Q OTHER <br /> NUMBER OF LIVING UNITS: _1 NUMBER OF BEDROOMS: C NUMBER OF EMPLOYEES: <br /> ❑ SEP T iC TANK T`fPE/w1FG 4C-. inPACIT'f J ---- 581 I OF CvMRARTir"ENTS <br /> ❑ GREASE TRAP TYPEIMFG �! I�yY-43 CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ LEFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES L1 LEACHING CHAMBERS #OF LINES QL— LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> FILTER BED WIDTH �ZlL, ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> U DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE <br /> ' ft <br /> 1 SEEPAGE PITS NUMBER � WIDTH 3 ft DEPTH �NEft <br /> �\ DISTANCE TO NEAREST WELL "`hDZ 1 ft FOUNDATION _Q PROPERTY LINE 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 /> Ml U ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNEDX TITLE t I—V i"I DATE <br /> F <br /> + 1 _ <br /> iL T-- <br /> 7'. <br /> Y <br /> �— <br /> . EPARTMEN7 SE CINLY <br /> Application Accepted Date 2r Area Employee tD# 7 7� <br /> Final Inspection By/ Date Cl SPECIAL PERMIT-Approved by <br /> Character of Soil to pth of 3 Ft: Pit/ ump Soil Character: <br /> COMMENTS 4X t? L M�: L <br /> PE SC Received Ch #I Amount Date Permit/ Invoice# Permit 1D# <br /> Cade INFO Byy as Remitted Service Request# <br /> © Z .rA l� SIM(0 PM <br /> 42-01 ONSITE WASTEWATER TRTMINT SYSTEM PERMIT <br /> 5121110 <br />