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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> a. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"°FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-R97 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP <br /> _ v`o s,r ��- D5 l <br /> CROSS STREET APN RCFL SIZE Y <br /> v <br /> ///��1 Q Jp� / po <br /> OWNER NAME f�f,Eb� i �7if 1 <br /> {� PHONE ! pv. ✓l7 y <br /> OWNER ADDRESS t 6 1'-tDQ i1.9— 'itbl CITY/STATE/ZIP <br /> CONTRACTOR PHONE '/7 U <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑CA2 ❑C-36 OTHER NUMBER ERPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST It 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 ROOF BEDROOMS: NUMBER OF EMPLOYEES: <br /> /J/�/� <br /> ❑ SEPTIC TANK TYPE/MFG I `� 1141, CAPACITY ^� a`� gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPF/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LME R <br /> ,,,❑3 LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES I _ LENGTH OF LINES 4VD R 07 <br /> DI STANCE TO N EA REST WELL ft FOUNDATION R PROPERTY LINE R <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> ❑ MOUNDED WIDTH ft LENGTH R - DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME R <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ✓_ 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> NIM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 _ <br /> (Q <br /> SIGNED TITLE cisme 41-- DATE T '�d s <br /> +s <br /> Y T <br /> EI D <br /> 005 <br /> UNTY <br /> Itz <br /> AL <br /> 9 / D PRT ENT <br /> di <br /> DEPARTMENT <br /> USE ONLY <br /> Application Accepted By Al T <br /> � Date '/ 10 Area Employee ID# <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 eck#/ Amount Date PermiU Invoice# Permit ID# <br /> Code INFO By as XRemitted Service Request <br /> •l //7 �Y L��� D 40 to <br /> !fl/ <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br />