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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3M°FL-STOCKTON CA 95202-(209)458-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS ,al Cm/ZIP y <br /> C r <br /> CROSS STREET APN,/��..�(-'�T -'ea /PARCEL SIZE 'S <br /> OWNERNAME f' t ` �PHONE Z6gX 4ZIZ-577-11 <br /> OWNER ADDRESS CITY/STATFJZIP �� <br /> ��[s1f �I•r� q <br /> CONTRACTOR U �A{Uy r l`r `t� PHONE <br /> CONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER ExPmATtoN DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X V <br /> ❑ PERT TEST # BUILDING PERMIT# .LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NF.W INSTALLATION REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF.BEDROOM$; NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ CREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISrANCETO NEAREST: WELL ft FOUNDATION ft PROPERTY LME ft Q <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> (ti <br /> LEACH LINESLEACHING CHAMBERS. #of LINES LENGTH OF LINES C 0� <br /> ,111 DISTANCETO NEAREST WELL ft FOUNDATION ft PROPERTY LINE. ft <br /> ❑ FILTER BED WIDTH R LENGTH ft DEPTH ft <br /> DIsrANCETONEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> ❑ MOUNDED WIDTH ft LENGTH ft DIM ft <br /> DISTANCE.TO NEAREST WELL ft FOUNDATION it PROPERTY LINE <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH R `_ <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> Q DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SEEPAGE PITS NU"'Ir` WtorH ft DEPTH ft <br /> D1SrANC1FTONEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION ANATHE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> NCP. TELA AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> INIMUM 24 HC. RADVAN NOTICE REQUIRED FOR lNSPE�f IONS-PLEASE.CALL 209)953.7697 /1T <br /> SIGNED _` TITLE_( n DATE /O L O <br /> R <br /> r0 <br /> SAIi 30POOPI 1•..,.e <br /> LA <br /> �7U �� /Oaf-• <br /> e <br /> s uz <br /> DEPARTMENT USE ONLY- - -- <br /> Application Accepted By Date 2. f- Area Employee ID# 49 <br /> Final Inspection By Date !L EJ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: I P(VSump Soil Chander: <br /> COMMENTSA3�tc: t t r`p F "cc 0.4 L A Gk L r a+6 M usT AF i b o *;:' S7 JK t/V -14 <br /> a <br /> PE SC Received Chec Amount Perfnw <br /> Code INPO B Cash Remitted Dote Service uest# Invoice# PermitiD# <br /> 42--i4 Ir ?-12--f. ;L3--C, <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> (71222003 <br />