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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> s SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"°FL-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT `C ALL(209)953-7697FORINSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ``i 2 17 S C- <, AN �� � �� .`"' \ ��7�ITY/ZIP <br /> CROSS STREET �' APN 5 ) l.'- ppRGEL SIZE 7 p <br /> "r OWNER NAME ) r ^ 'I PHONE <br /> I l , <br /> 1 J <br /> OWNER ADDRESS �' 4 � ('- �-I � i---L� CITY/STATE/ZIP <br /> CONTRACTOR PHONE 3 Z t <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> U PERC TEST # Z BUILDING PERMIT# LAND USE APPLICATION#)} •�'.'.i i:A< <br /> TYPE OF WORK: ❑ NEW INSTALLATION - ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENTS ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: i <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS i <br /> ❑ .GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS 11111 <br /> j ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL It FOUNDATION ft PROPERTY LME it <br /> ❑ LIFT STATION SIZE TYPE OF Pump ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) III <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS "- #OF LINES LENGTH OF LINES <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> r A,i <br /> ❑ FILTER BED WIDTH R LENGTH ft DEPTH It <br /> s DISTANCE TO NEAREST WELL - ft FOUNDATION ft PROPERTY LINE R C. <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft 1 <br /> 1 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION fl PROPERTY LME ft G I <br /> ❑ SUMPS WIDTH. - ft-'.LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST. WELL. - ft FOUNDATION ft PROPERTY LME ft T• <br /> I <br /> i <br /> ❑ DISPOSAL PONDS WIDTH - ft LENGTH - ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R - PROPERTY LME It <br /> ❑ SEEPAGE PITS NUMBER - WIDTH ft DEPTH _ ft r' <br /> DISTANCETO NEAREST WELL - ft.FOUNDATION ft PROPERTY LME B <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY 1 <br /> - ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. "Al <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 �•v i <br /> i SIGNED � _ -.__-. � ____ �---•— TITLE ��. � DATE ` 1.4 <br /> I <br /> I � <br /> " <br /> N 1 <br /> I � � <br /> I r' <br /> O N <br /> DEPARTMENT YSE ONLY <br /> yL <br /> Application Accepted By Date 9 1 1'4!(,,1 Area Employee ID# 6'V <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 /> { <br /> PE SC ReceivedE 'Check#/' Amount Permit/ Invoice# Permit ID# <br /> Code In FO B r Cash Remitted (Date/.. Service Re uest# <br /> 1 <br /> 42-02-001 ONSITE WASTEWATER PERMIT 1 <br /> 12/228003 <br />