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r <br /> 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 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP y <br /> � 1 <br /> m <br /> CROSS STREET APN PARCEL SIZE Y <br /> 0 <br /> O <br /> A <br /> OWNER NAME PHONE s <br /> OWNER ADDRESS - CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS .__ CITY/STATE/ZIP <br /> r... LICENSE C-42 C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> I�� 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 It FOUNDATION ft PROPERTY LINE ft <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 ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH It DEPTH AA w,. ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LIN ft <br /> ❑ MOUNDED WIDTH It LENGTH If DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN y I K — ft <br /> ❑ SUMPS WIDTH It LENGTH ft DEPTH SAJV - " 4U15 ft <br /> w DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPEW l_ kdul <br /> Rn•'N_ ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH j� �AmCI1J����r► ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE NT ft <br /> Q SEEPAGE PITS NUMBER WIDTH ft DEPTH It <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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE - DATE <br /> I <br /> I <br /> I <br /> DEPARTYEN TUSEONLY <br /> Application Accepted By Date Area Employee ID# <br /> Final Inspection By Date I..I SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> - - - - - — - - <br /> j PE SC Received CheckiN` Amount Permitl <br /> Code INFO B Cash Remitted Date Service Request# Invoice# Permit ID# <br /> 42-;? ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4,2411 <br />