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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E MAIN STREET-STOCKTON CA 95202-(209)488-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> CITU/ZiP <br /> CROSS STREET 'L6tY G ApN 16 /(f PARCEL SIZE <br /> I OWNER NAME r _ <br /> j I ! PHONE <br /> OWNER ADDRESS <br /> CITY/STATE/ZIP <br /> CONTRACTOR <br /> �� PHONE <br /> CONTRACTOR ADDRESS CITYISTATEIZIP <br /> I <br /> LICENSE it C-42 r�C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT LAND USE APPLICATION# -� <br /> TYPE OF WORK: r NEW INSTALLATION REPAWADDITION _ ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT - OUT•OF.SERVICE SEPTIC SYSTEM - DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE D COMMERCIAL /OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: /NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPVMFG (i CAPACITY ? gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL 1� ft FOUNDATION ft PROPERTY LINE }t <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES _� LENGTH OF LINES <br /> DISTANCE TO NEAREST WELL��ft FOUNDATION ft PROPERTY LINE _ft <br /> ❑ FILTER BED WIDTH ft LENGTH II DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEARESV WELL ft FOIINnATI ft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER Z WIDTH <br /> �i _ ft DEPTH It <br /> DISTANCE TO NEAREST WELLt'r' fl 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. 1 <br /> MINIMUM 24 HOUg ADVANCE NOTICa REQUIRED FOR INSPECTIONS �L ASE CALL(209 953-769 <br /> SIGNED TITLE t�Ys// <br /> I <br /> t <br /> 5 <br /> z <br /> I <br /> EE A An <br /> D PARTMENT NLY <br /> Application Accepted B Date Z Area Employee ID* <br /> Final Inspection ey _ Date Z- ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to 04Wth of 3 Ft: P Sump Soil Character: <br /> COM NTS <br /> 1 PE SC Received Com( Amount Date rruu Invoice# Permit ID# <br /> Code INFO B �sp�' Remitted Service Re uest# <br /> �1 t <br /> n2 0' ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />