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ONSITE WAS'�'WATER TREATMENT SYS""' M PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3R°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> CITY/ZIP I _ <br /> CROSS STREET APN PARC FL SIZE D <br /> 0 <br /> _ o <br /> OWNER NAME PHONE u <br /> m <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> `CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS - CITV/STATE/ZIP <br /> LICENSE ❑CA2 ❑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 ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OFCOMPARI'MENTS r. <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> .... ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ^ <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) C <br /> ^ ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES H <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE <br /> ^ ❑ FILTER BED WIDTH ft LENGTH ft DEPTH H <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH it <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It <br /> ❑ SUMPS WIDTH It LENGTH ft DEPTH ti <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it <br /> ❑ DISPOSAL PONDS. WIDTH ft LENGTH ft DEPTH ft <br /> ^ DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft _ <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH H\ Y <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE H <br /> ^ 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL HE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE;CALL(209)953-7697 _ <br /> SIGNED TITLE DATE <br /> I <br /> ti <br /> t/ . <br /> T <br /> - JEP'VI O <br /> TH DE PAI iTh IEN <br /> EPARTMENT USE ONL ' <br /> r <br /> Application Accepted By 'Date 1 Area Employ=]D# 7 7 <br /> Final Inspection By Date-- ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#Y Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Re uest It <br /> 1 <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> I V22/200! 071,13 <br />