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za-/a 30 <br /> 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 / �' 1 CITY/ZIP <br /> CROSS STREET UU APN , I PARCEL SIZE I --2 <br /> K <br /> l / /y 7 <br /> OWNER NAME �' C �I 1 J�I PHONE c <br /> OWNER ADDRESS i I)t-C- CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE C-42 C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: I`]~ ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/A TERNATIVE l' <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: {\RESIDENCE COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ¢� SEPTIC TANK TYPE/MFG �rn C / `_ _ CAPACITY IG� (1 921 #OF COMPARTMENTS �- <br /> /❑ GREASE TRAP TYPE/MFG CAPACITY 921 #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ��'L>I IL I56r ft FOUNDATION 11 ft PROPERTY LINE Z ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP U PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> t <br /> 51 LEACH LINES LEACHING CHAMBERS #of LINES LENGTH OF LINES <br /> Z , ft <br /> DISTANCE TO NEAREST WELL Yl FOUNDATION �ft PROPERTY LINE <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 ii <br /> O SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL fl 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 /> 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-7697 <br /> SIGNED j (� J.tom(_( � � TITLE k-. DATE <br /> T <br /> Ck <br /> T) I - . <br />