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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3-FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EX�JPIIR,.E�S�1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS c t- CITY/ZIP �/ 45A' v' <br /> �` /��� � yS•4f � <br /> CROSS STREET 071-1 -. «17. APN -Z 570—f 7 n' V PARCEL SIZE -f==6"( a <br /> v <br /> L — (4 Cc 4L of <br /> OWNER NAME � oc � cGK h'e� PHONE <br /> OWNERADDRESS S/4'aff CITY/STATE/ZIP <br /> CONTRACTOR G 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# -O C' .- LAND USE APPLICATION# <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: -3 NUMBER OF EMPLOYEES: <br /> �- SEPTIC TANK TYPE/MFG 1..� CAPACITY 500 gal #OFCOMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG l CAPACITY gal #OF COMPARTMENTS <br /> ElPKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LME / O R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES _ LENGTH OF LINES /15 ft <br /> DISTANCE TO NEAREST WELL 106 ft FOUNDATION • f V R PROPERTY LINE <br /> ❑ FILTER BED WIDTH R LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ MOUNDED WIDTH R LENGTH R DEPTH R IN <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LME ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LME R <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft 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 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE C:2,Ai.fC DATE <br /> ffE <br /> P <br /> DEPARTMENT USE O V [� S <br /> Application Accepted By Date �11 Area 2/ Employee ID# <br /> Final Inspection By Date /�'05 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth o3 Ft: Pitisump Soil Ch ncter: <br /> COMMENTS llji_r t-, i_c7r 0E- .eve cc�i a 2-Chs <br /> PE SC Received Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service R uuest# <br /> 2!I (I"J a! SD•cJ d <br />