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ONSITE WASTEWATER TREATMENT SYSTVM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"FL-STOCKTON CA 9$202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1�J �� �\ •,-- CITY/ZIP O y <br /> 2 �1� 4 m <br /> CROSS STREET APN OA /' �-T�' Q PARCELLE 1 > <br /> 0 <br /> f A <br /> OWNER NAMEAPHONE �( y <br /> OWNER ADDRESS �� \v VV - 7�"-A sl CITY/STATE/ZIPo\\ <br /> CONTRACTOR PHONE e T�� <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# — <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAnUADDITION ❑ 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 #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION R PROPERTY LINE R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ SUMPS WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION •R,.,, PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION R PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> I 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEAS CALL(209)953-7697 <br /> SIGNED TITLE 4f: DATE Z <br /> ( <br /> 7 1 <br /> QL IN <br /> H "v+ -E + — <br /> H MENT, <br /> I M11 111- ' 7-1 <br /> r DEPARTMENT SE ON <br /> Application Acc pted y Date Area Employee ID# <br /> Final Inspection Q' Date cz�— -97 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3;F Pit/Sump Soil Character: <br /> COMMENTS S <br /> �Q <br /> PE SC Received heck#!/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO BY Remitted Service Request# <br /> 222 ZI 3S <br /> ONSITE WASTEWATER PERMIT <br />