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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(209•953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS I e CITY/-LIP <br /> J� '1 M <br /> CROSS STREET ,_ t , [ �_J �.C} APN Ltd-1 L 1— PAR L SIZE • O <br /> 1--: <br /> ' OWNER NAME •6, �N.n/s �-1 7-- PHONE <br /> m <br /> r L7L t <br /> OWNER ADDRESS CITY/STATE/ZIP I'V <br /> CONTRACTOR F � PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: R GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # L BUILDING PERMIT# LAND USE APPLICATION#, <br /> a TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: t <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS _ <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG 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 /> 1 <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES it lt" <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH A DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE fl <br /> ❑ MOUNDED WIDTH _ It LENGTH ft DEPTH ft <br /> DISTANCETO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> ❑ SUMPS WIDTH tl LENGTH ft DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY U. ft <br /> ❑ DISPOSAL PONDS WIDTH 0 LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SEEPAGE PITS Nt'MBER WIDTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE I ft <br /> I HEREBY CERTIFITHAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL,BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDINANCES.STATE LAWS AND RULES AND REGULATIONSQF SAN JOAQUIN COUNTY. <br /> y <br /> MINIMUM 241 HiO 1R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 q <br /> SIGNED E TITLE - DATE 7 .1 O• Cl l- <br /> 9 <br /> 1 <br /> ` P <br /> t4 <br /> M N AL <br /> vd-fliD <br /> 1 j r DEPARTMENT SE \LY' rN <br /> Application Accepted By� r /1-._L Date .Area Employee ID# J, <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character If Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS, e <br /> PE SC Received Check#/ Amount Permit/ <br /> +_ Code INFO B �aah Remitted Date Service Re nest p Invoice# Permit ID# <br /> ?'c ('. <br /> 42-02-001 ONSITE WASTEWATER PERMIT <br /> I2/22RDO3 <br />