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4NSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1068 E.HAZELTON AVENUE—STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECT70NS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 115 <br /> JOB ADDRESS CITYIZIP <br /> CROSS STREET ')e_- -f �-� APN 6 ���� �0 _-PARCEL SIZE <br /> '-� ✓Y[ <br /> OWNER NAME � PHON � <br /> OWNER ADDRESS r L CITYISTATEIZI`P <br /> CONTRACTOR \ "�rl PHONE oC 6 /� J <br /> CONTRACTOR ADDRESS 4,�"5 CITYISTATE/ZIP 4 <br /> LICENSE 110C-42 ❑❑C-365 OTHER NUMBER ExPIRATION DATE © � <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: COOTdinates X Y <br /> ❑ PERC TEST # 1 1 BUILDING PERMIT# t 3 O I Pt 7,5 LAND USE APPLICATION# <br /> TYPE OF WORK: U NEW INSTALLATION jC REPAIRIAODITION L ENGINEER DESIGNED/ALTERNATIVE <br /> El 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 TYPEIMFG C�7n _ CAPACITY I4P C cO gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ff <br /> © LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS ` #OF LINES 410 _ LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL l 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 N£ EST WELL `9-0 ft FOUNDATION ft PROPERTY LINE ft <br /> © SUMPS WIDTH ft LENGTH AZ' <br /> ZI ft DEPTH f/ ft <br /> DISTANCE TO A EAREST WELL ft FOUNDATION ft PROPERTYLINE 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 /> 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 /> ? ,--g1N1MUM 2 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 3-7y697 2 <br /> IGNED LE DATE <br /> IMED <br /> s <br /> t — <br /> S J A UN <br /> i N iR E T L <br /> Into <br /> DEPARTMENT USE ONLY ,Y <br /> Application Accepte Date_ 3 Area Employee ID# <br /> Final Inspection Date ❑ SPECIAL PERMIT Approved by <br /> Character of Soil to Dei h of 3 Ft: Pit! mp Soil Character: <br /> COMM NTS 4- <br /> < <� <br /> PE Sd Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO EIv Cash Remitted._ Service Request# <br /> Xto t <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/24112 <br />