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ONSITE WASTEWATE REATMENT SYSTEM PERMITL�a� 1 <br /> JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT304 E WEBER Ave-3"°FL-STOCKTONCA 9520:,. ,,09)468-3420 <br /> [IAN <br /> NON-REFL1NIyABLE PERMIT CALL 209 953-7697 FOR INSPFCTIONti EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ill oaanDRess <br /> CITYlLZ%IP—^+ r !r•r PARCEL SIZE ? -Rn <br /> OSSSTREET APNaI <br /> II <br /> � <br /> PHONE `fin• i <br /> OWNER NAME <br /> CITYISTATFJZIP <br /> WNER ADDRESS <br /> .T PHONF, r <br /> CITY/STATVZIP <br /> CONTRACTOR ADDRESS <br /> NUMBER EXPIRATION DATE <br /> C, <br /> LICENSE LlCA2 ❑C-36 OTHER <br /> R Y <br /> WATER TABLE DEPTH: C• �', <br /> GEOGRAPHICALINFORMATION: Coordinates X ! <br /> LAND USE APPLICATION# <br /> PERC TEST # L" BUILDING PERMIT# <br /> I ❑ REPAIRIADDITION [3ENGINEERDESIGNED/ALTERNATIVE <br /> TYPE OF WORK: C1 NEW INSTALLATION ❑ DESTRUCTION <br /> r ❑ REPLACEMENT <br /> ❑ COMMERCIAL (] OTHER <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE '- � <br /> NUMBER OF LIVING UNITS: <br /> NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES= <br /> CAPACITY gal #OF COMPARTMENTS <br /> SEPTIC TANK T111/MFG <br /> ! <br /> CAPACITY gal #OF COMPARTMENTS i <br /> ❑ GREASE TRAP TYPE/MFG I <br /> ft FOUNDATION <br /> L] PKC TX PLANT DISTANCE TO NEAREST: WELL <br /> ft PROPERTY LINE ft it <br /> L7 LIFT STATION SIZETYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> I <br /> F <br /> ❑ LEACH LINES ft- <br /> E3 CHAMBERS <br /> #OF LINES LENGTH OF LINES ft <br /> ft FOUNDATION ft PROPERTY LINE ft �i <br /> DISTANCE TO NEAREST WELL n , <br /> ❑ FILTER BEPWIDTH <br /> ft LENGTH ft DEPTH ft <br /> DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft r <br /> s ft DEPTH Fa MOUNDED WmTR ft LENGTH <br /> DISTANCE TO NEAREST WELL °. ft FOUNDATION ft PROPERTY LINE ft <br /> ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> �❑ DISPOSAL PONDS WIDTH ft LENGTH <br /> R DEPTH ft <br /> F! DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LING R <br /> p SEEPAGE PITS NUMBER WIDTH <br /> ft DEPTH ft <br /> DISTANCE TO NEA REST WELL ft FOUNDATION ft PROPERTY LINE ft j <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES.STATE SAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY.- <br /> 14 <br /> 1,IINIMUW4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASECALL,(2091953-7(,97 r I <br /> _ - �t _ DATE <br /> SIGNED TITLE <br /> i Y �--� �-- f �. _...- <br /> i <br /> r I I N <br /> 3 My%d- <br /> fir_ :4� z a __ � p U N• <br /> — <br /> a: 4 e Ra ` <br /> 'K'4 uutre __ —--— .J <br /> jj <br /> 1 F <br /> k <br /> DEPARTMENT IJSE NLY - <br /> - Date Z-/� G n.�. Area -1 4 ;Employee 1D# <br /> g' 'sApp'cation Aceepted-By f r_ - - !!! <br /> s kSPECIAL PERMIT Approved?Y, <br /> Fiaal InspeetlullBy-'' $v e`. k _ 'ti- Deie �,. .. _ <br /> ° CharacteF[oI Soil to Depth or <br /> PIUSump Soll Character: - <br /> � <br /> PE -- SC Received:l I Chec Amount 'Permit/.' Invoice# ,Permit ID#- <br /> ' Da <br /> -CodeInco ash AemlttedTr - Service Re uest#- <br /> -.'4 <br /> ONSITE WASTEWATER PERMIT' <br /> -1211272003 ' <br /> i <br />