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1 <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E MAIN STREET-STOCKTON CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT 7 CALL(209)953-7697 FOR INSPECTIONS / EXPIRES'I YEAR FROM DATE ISSUED <br /> JOB ADDRESS I//// E / - _ CITY/ZIP <br /> CROSS STREET^ �(--m's APN PARCEL SIZE <br /> PHONE 4JS-7OS'I�3S <br /> OWNER NAME /_` 141 7�1 eWN <br /> OWNER ADDRESS CITYISTATEIZIP I nI I,n/IP �T�JAM <br /> CONTRACTOR ICJI/ JGyY� r� �nh�- PHONE 'Z 61-S'DZ7 <br /> CONTRACTOR ADDRESS -_�/DLrJ F /Yl,/11S/�✓ /i1LS1� CITYISTATEMP lel-- <br /> LICENSE DkC-42 ❑C-36 OTHER NUMBER,_y5�1ONS-- EKPIRATION DATE,��- /-Ok <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION PL REPAIR/ADDITION n ENGINEER DESIGNED(ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL -1 OTHER <br /> NUMBER OF LIVING UNITS= NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY - gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) \ <br /> 1 <br /> ❑ LEACH LINES U LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FCIUNDAT10N ft PROPERTY LINE ft m <br /> ❑ FILTER BED WIDTH ft LENGTH _ ft DEPTH ft <br /> DISTANCE TO NEAREST WELL _ft FOUNDATION ft PROPERTY LINE It <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It <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 It <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH _ ft DEPTH!_ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER IO WIDTH S ft DEPTH aS ft <br /> DISTANCE TO NEAREST WELL ;7 f -ft FOUNDATION oNC It PROPERTYLINE 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 24 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(2119)953.7697 <br /> SIGNED TITLE DATES <br /> A' <br /> aj <br /> V <br /> A <br /> I <br /> 5 O M t3 <br /> E1t1T D <br /> u' <br /> J v <br /> DEPARTM T EP NL <br /> Application AcceptP�kDate 0/ Area _ Employee ID# (� <br /> Final Inspection Date---7�/LU &�. SPECIAL PERMIT-Approved by <br /> Character of Soil epth of 3 Ft: PI ump Soil Character: <br /> COMMENTS NS -- <br /> •--- <br /> .��( <br /> PE SC Received Ch Amount Permit/ <br /> Code INFO a ash emitted Date eq ues Invoice# Permit 1D# <br /> zsl sa cD 'S spa <br /> WA TR 'NT SYSTEM PERMIT - <br /> 10/4107 <br />