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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 95/3--7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS (j CITY/ZIP <br /> CROSS STREET APN lJ .L PARCEL SIZE ` T <br /> 0 <br /> OWNER NAME ^�H./y,,�/} cPHONE6e n, <br /> OWNER ADDRESS v f ��>�L� AJit CITY/STATE/ZIP J / �7(.I/J <br /> CONTRACTOR ��/Lt R i-C /�T,r '! �C V C! PHONE <br /> CONTRACTOR ADDRESS I/�3 1 �Jj <br /> o� CJ7. <br /> J�' ���(1 t.J :- CITY/STATE/ZIP � ) U '— <br /> /% . <br /> LICENSE ❑_C-42 ❑❑C-36 OTHER NUMBER ) EXPIRATION DATE V 2 v <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: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP E3PKG TX PLANT L3 SAND OIL SEPARATOR(ENCLOSEDSYSTEM) <br /> L3 LEACH LINES `I LEACHING CHAMBERS t ,,,� - #OF LINES LENGTH OF LINES U O ft <br /> DISTANCE TO NEAREST WELL_/—'J' <br /> JJ 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 /> 0� SEEPAGE PITS NUMBER C( �� WIDTH C-�i7 �.� U ft DEPTH ft <br /> DISTANCE TO NEAREST WELL / -> ft FOUNDATION /J ft PROPERTY LINE S 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 /> MINIMUM 4"OUR.ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 <br /> SIGNED '� TITLE ������h!U DATE <br /> Un <br /> /N <br /> F <br /> M <br /> Wr7 <br /> PARTMENT USE ONLYApplication Accepte yDate , Area Z [ ` Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to De th of 3 t: PiUSump Soil Character: <br /> COMMENTS - OO <br /> PE SC Received Check Amount Permit/Code IF B ash Remitted `Date Service Request# Invoice# Permit ID# <br /> 21 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />