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ONSITE WASTEWATER TREATn,...�T SYSTEM PERMIT <br /> SAN JOAQUINC*VNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3"°FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PEJtMI , CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS v `�'I �- CITY/ZIP ,L- '^� --�-• ( f; - i(' � o <br /> ` CROSS STREET L' PARCELSIZE C <br /> a <br /> OWNER NAME !t'/� T� vi,L+ .. L1 PHONE <br /> OWNER ADDRESS t CITY/STATE/ZIP <br /> CONTRACTOR <br /> PHONE <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 /> PERC TEST #:::::= BUILDING PERMIT# LAND USE APPLICATION# Y - <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 TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> haw ❑ 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 ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> G <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> r.. ❑ DISPOSAL PONDS WIDTH _ ft LENGTH ft DEPTH ft - <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH -ft- <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <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.Hf)UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED i-` d"..^--.-c--tet {t.�.....oc, .-�_`', T t--7 TITLEf-r�.. -.�r�DATE - �• L. yc� <br /> ionj i <br /> i <br /> o: <br /> k i <br /> f <br /> - y <br /> I <br /> .39 <br /> i s --r'• S <br /> i <br /> S O M N <br /> ILTi D <br /> DEPARTMENT USO ON <br /> Application Accepted By r-=� - `"��. Date �1� 1 Arra 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 Check#/ AmountPermit/Code INFO ,B Cash Remitted Date Service Request# Invoice# Per <br /> ID# <br /> 42-02-00I ONSITE WASTEWATER PERM/ <br /> I ninnni <br />