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ONSITE WAST" 'VATER TREATMENT SYSTV I PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE*fTKTMENT 304 E WEBER Av,. 3-FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT ��ii CALL(209)953-7697 FOR INSPEC'TION'S EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS S /Z IVC CITY/ZII�P (G� I <br /> CROSS STREET 1/®(^�I (�f APN I,j _ 3 T PARCEL SIZE tv <br /> (� I IrM <br /> OWNER NAME (/ L 1 (h V PHONE <br /> OWNER ADDRESS /�� ,T� CITY/STATE/ZIP t <br /> CONTRACTOR WII �I�(� PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE N <br /> WATER TABLE DEPTII: ft GEOGRAPHICAL INFORMATION: Coordinates X Y 7 <br /> ❑ PERC TEST(S) NUMBER LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDIT ON ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT 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 COMPARTMENTSSl <br /> r-- <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE it r <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE tt <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH tt <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS WIDTH ft LENGTH ft DEPTH tt <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE L WS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIMUM 24 HOUR ADV NCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7697 <br /> SIGNED I TITLE DATE <br /> 71 <br /> f � / <br /> SA14 J A JIN GO NI'! <br /> F Sltl <br /> m e T nl <br /> DEPARTMENT USE—IONLY _ <br /> Application Accepted BY � I Date ` Area Employee ID# <br /> Final Inspection By Date c5 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to De of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS TA N i� D i✓S"�(��I C r I G S %fJf4'��1� �J jL�ij��Gl�zs �cL t�!�r/�rZ� <br /> PE SC Received heck Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By ash Remitted Service Request# <br /> 2-L 3 SAI0033UR <br /> 42-01-001 <br /> I�nim ONSITE WASTEWATER PERMIT <br />