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e y 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 'I YEARFROM DATE ISSUED <br />JOB ADDRESS I , �� CITY/ZIP �� ) �C9 r� <br />gal # OF COMPARTMENTS <br />SC <br />INFO <br />o 7:57,'sem-1 <br />Imo/ <br />I <br />�`� l�or APNI�SISO`Il e--' <br />CROSS STREET a- <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY <br />PARCELSU <br />Permit/ <br />Servic- "--est# <br />p� <br />/� nr�,ze pyo y� <br />OWNER NAME IV f'► 42 C 30 �L( Yyl 1' '` 1 1�"j2-I'(/(//4 PHONE <br />ft FOUNDATION <br />ft PROPERTY LINE <br />OWNER ADDRESS 1 j/y / V ( IC '�JCITY/STATE/ZIP <br />❑ LIFT STATION SIZE TYPE OF PUMP <br />CONTRACTOR �V�l �Itic r PHONE <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />❑ LEACH LINES 1 LEACHING CHAMBERS <br /># OF LINES <br />LICENSE ❑❑C-42 ❑❑C-36 OTHER NUMBER EXPIRATION DATE <br />ft <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: Ci NEW INSTALLATION I I REPAIR/ADDITION Ll ENGINEER DESIGNED /ALTERNAT VE <br />❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM k, DESTRUCTION SC iIL C h R <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />SC <br />INFO <br />o 7:57,'sem-1 <br />Received <br />By <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />Permit/ <br />Servic- "--est# <br />Invoice # <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ LIFT STATION SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES 1 LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ FILTER BED WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ MOUNDED WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SUMPS WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />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 />4AXIMUM48 O QVANCE NOTICE REQUIRED <br />FOR INSPECTIONS - PLEASE CALL 209 952:W7 <br />t� [ C�V I <br />SIGNED <br />TITLE -�- <br />DATE <br />?> <br />A <br />N o <br />ry <br />1-4;FADS <br />R <br />I III <br />T <br />DEPARTMENT USE QNLY <br />i <br />Application Accepted By <br />Date J 0/2/ <br />Area Employee ID# _ <br />Final Inspection By <br />Date <br />❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of Ft: <br />Pit/Sump Soil Character: <br />COMMENTS jf0;-,jy?f� j����o o�b�al �N>n/Pr►' tli/x%11 ���-C <br />�cs,�r (�/ �r-L .tS�i�-rte ,, <br />42-01I 1,33 SSC J�q 7 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14118 <br />PE <br />Code <br />qd a) <br />SC <br />INFO <br />o 7:57,'sem-1 <br />Received <br />By <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />/s aff4wi-s—KoAq. <br />ate <br />Permit/ <br />Servic- "--est# <br />Invoice # <br />Permit ID# <br />42-01I 1,33 SSC J�q 7 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14118 <br />