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rP"'1 <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-3Y°Fl.,-STOCKTON CA 95202 -(209)468-342D <br /> NON-REFUNDABLE PERMIT CALL 209 953-7 97 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> J <br /> JOB ADDRESS L CITY/ZIP <br /> CROSS STREET A P N �W b/ PARCEL SIZE > <br /> OWNER NAME 1- ",�J_��J//�if��� PHONE D 0/ -S57— <br /> U <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR PHONE /6 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C42 ❑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: ❑ NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT L DESTRUCTION om) <br /> INSTALLATION WILL SERVE; ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> '''III777rrr NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> yu SEPTIC TANK TYPE/MFG ' Z _ CAPACITY Z ' gal #OF COMPARTMENTS <br /> ✓�❑..• GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ LIFT STATION SIzE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES R <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE R <br /> ❑ FILTER BED WIDTH R LENGTH Fl DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH R LENGTH R DEPTH Fl <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE fl <br /> ❑ SUMPS WIDTH R LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> ❑ DISPOSAL PONDS WIDTH R LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24OUR ADV CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE,CALL 12091 953-7697 <br /> SIGNED -./� �� TITLE DATE <br /> f <br /> V! b UE <br /> O N <br /> LLL Eq <br /> .PARTMENT USE 'LV - 9 <br /> Applicstlon Accept Date Z Area Employee ID#q f <br /> Final Inspection Date //� ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to h of 3 Ft: Pit/Sump Sell Character: <br /> COMMENTS 1>1v!? I,dT CJF 2El.00tb ' d7/G C9x L��/. j 2� 4� t= U <br /> PE SC <br /> INFO heckil/ Amount PermiUu <br /> Date Invoice III PermitID# <br /> Code INFO B Cash Remitted Service Re eat# <br /> S t1 50°' IWO 6 S C1 <br /> 42-02-001 ONSITE WASTEWATER PERMI'. <br /> 12!224003 <br />