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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE -3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 204 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITYIZIP 7_ _ <br /> CROSS STREET APN ©,42 <br /> f 0_3 — PARCEL SIZE ! v <br /> �J z <br /> OWNER NAME 14maz r/ t Au x PHONE <br /> OWNER ADDRESS CITYISTATEIZIP <br /> CONTRACTOR <br /> � PHONE <br /> CONTRACTOR ADDRESSCITY/STATEIZIP <br /> LICENSE 42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# _ LfOXWO- ._ LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> L3 REPLACEMENT - L) DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: ♦♦ �y NUMBER OF EMPLOYEES: �J <br /> SEPTIC TANK TYPEIMFG CAPACITY y gal #OFCOMPARTMENTS t✓ <br /> ❑ CREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑- SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERSy #OF LINES -_ .-- LENGTH OF LINES � ft <br /> DISTANCE TO NEAREST WELL— �._Z ft FOUNDATION —LJO o ft PROPERTY LINE '[_Q _ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION fl PROPERTY LINE ft I <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEEA ST WELL ft �F�OUNDATION R PROPERTY <br /> INE R <br /> SUMPS WIDTH fp ft LENGTH �L/ ? _ft DEPTH a ft <br /> DISTANCE TO NEAREST WELL��Z ft FOUNDATION 7th , R PROPERTY LINE <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH fl DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION R PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <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 /> MINIMUMMURANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNER TITLE. DATE <br /> �..-al �e i ! aAl <br />