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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS V ✓ CITY/ZIP C� —4X <br /> CROSS STREET APN UPARCEL SIZE <br /> v <br /> � o <br /> OWNER NAME PHONES <br /> OWNER ADDRESS U C CITY/STATE/ZIP <br /> CONTRACTOR & � PHONE <br /> CONTRACTOR ADDRESS �01� v(�Y U 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# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: I RESIDENCE ❑ COMMERCIAL �J ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: L /�� /� NUMBER OF EMPLOYEES: <br /> (, —SEPTIC TANK TYPE/MFG 1 CAPACITY oC�Z/ gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> I 1 T <br /> DISTANCE TO NEAREST: WELL 5-0 ft FOUNDATION / (/ ft PROPERTY LINE (3 ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ 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 ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <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 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIA4W 48 HOUR-ADVA4VICEN TICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 -7697 <br /> SIGNED �� TITLE G-- l� DATE <br /> TO 17 FV <br /> A <br /> N I C <br /> ex 7T p A <br /> T <br /> DEPARTMENT JJSE ONLY <br /> Application Accepted B Date 3 Area Employee ID# <br /> Final Inspection By kin Date Z ❑ SPE IAL PERMIT-Approved by <br /> Character of Soil to De th of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS `S h. �� �' <br /> d <br /> PE SC Received hec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />