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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> f A <br /> SAN OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE.-3°p FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> A�7 ja� CITY/ZIP <br /> JOB ADDRESS �J 1 �-1] (,��t/'}�/nx <br /> CROSS STREET �� APN i��3�"`� `• PARCEI.SIZE__ __ z <br /> OWNER NAME S�S II�^ iRa����TQ-T -i� PHONE n <br /> OWNER ADDRESS V\ CITY/STATFJZIP [:I4-- <br /> PHON <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 C-36 OTHER NUMBER EXPIRATION DATE - <br /> WATER TABLE DEPTH: fl 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 ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE RCIAL ❑ OTHER <br /> NUMBCOMMEER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPF/MFG CAPACITY gal It OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCF.TO NEAREST: WELL ft FOUNDATION fl PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) I <br /> C> <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES lt <br /> DISTANCE.TO NEAREST WELL ft /\FOUNDATION ft PROPERTY LINE ft <br /> FILTER RED WIDTH L4 0 1 ft LENGTH L,t 1, ft DEPTH 61/ It <br /> DISTANCE TO NEAREST WELL :30 inp ft FOUNDATION t It 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 fl DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION Il PROPERTY LINE fl <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 It DEPTH ft <br /> DISTANCE TO NEAREST WFLL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL RE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> lti/lJ' UM 24 HOUR ADVANCE.NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED <br /> t.✓ETt� I'� TITLE nLU I�C.IDATE <br /> 0 <br /> I <br /> S � <br /> CO O S <br /> E P <br /> h <br /> JfIT <br /> ! II <br /> !I <br /> ... PART MFNT -.0.1-Y - qQ <br /> Application Accepted B — Dale Area EmpI// / <br /> loyce ID# <br /> Final Inspection By I, — -S O ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pil/Su Soil Character: <br /> COMMENTS r <br /> PE SC Received c Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By sh Remitted Service Re uest# <br /> SKr,or</ 41 5 r </ rz ftar-h o-r��JO.'r cr rr�ti ONSITE WASTZWATER PERMyT <br />