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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 �� I <br /> CITYZP <br /> CROSS STREET T�jj /V ��/ APN0 2— <br /> PARCEL SIZE 'T tom' <br /> OWNER NAME G/l/dC+/.^-r PHONE <br /> OWNER ADDRESS _ CITY/STATE0P� l Q <br /> CONTRACTOR A G PHONE <br /> CONTRACTOR ADDRESS (S CITYISTATE/ZIP <br /> LICENSE * C-42 i i C-36 OTHER Y4 <br /> NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# 1�i) G-1 to 3_ 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 .9' COMMERCIAL I OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG CAPACITY % L gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY� gal #OF COMPARTMENTS_ <br /> DISTANCE TO NEAREST: WELL �) �' ft FOUNDATION �T It PROPERTY LINE f R <br /> ❑ LIFT STATION SIZE TYPE OF PUMP Ll PKG TX PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES LEACHING CHAMBERS #OF LINES _ LENGTH OF LINES Z�11) ft <br /> DISTANCE TO NEAREST WELL 5 it FOUNDATION it PROPERTY LINE S T It <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE It <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE it <br /> ❑ SUMPS WIDTH it LENGTH ft DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH it <br /> DISTANCE TO NEAREST WELL It FOUNDATION—it PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL it 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 /> MINI V HOUR ADVANOE NOTICE REQUIRED FOR INSPECTIO S-PLEASE CALL 209 953-7697 <br /> SIGNED �� TITLE /!7:Z7 <br /> y DATE <br /> I Lat. <br /> N Joko I <br /> R M <br /> -------------- <br /> Z R <br /> ) DEPARTMENT O L <br /> Application Acceotad 6 Date Area Employee ID# <br /> Final Inspection ByhhII!! Date�� i SPECIA IT-Approved by <br /> Character Of Soil to D pth of 3 Ft: Pit/ ump Soil Character: <br /> COMMENTS <br /> PE SC Received Check Amount Date PermiU Invoice# Permit ID# <br /> Code INFO B Remitted _ Service Re uest# ___.__ <br /> 21 I J �' e <br />