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ONSITE WAST 'ATER TREATMENT SYSTZ PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 E h.,.N STREET-STOCKTON CA 95202—(209)468-3420 <br /> NON—REFUNDABLE PERMIT Pq CALL I} )953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUP,D <br /> JOB ADDRESS " } CITY/ZIP!/ ` <br /> CROSS STREET APRT '`�© PARCEL SIZE[ 7o7c)l ✓ v <br /> OWNER NAME <br /> OWNER ADDRESS _ � � CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑ C42 ❑ C-36 OTH NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordina X Y `V <br /> ❑ PERC TEST # BUILDING PERMIT AND USE APPLICATION# ` <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDI ION O ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> ii INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER 1 <br />` NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> r ❑ SEPTIC TANK TYPEJMFG� CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPFIMFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> O LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES O LEACHING CHA #OF LINES LENGTH OF LINES OL/ ft <br /> DISTANCE TO NEA 1 S WEL FOUNDATIO 1 ft PROPERTY LINE $ <br /> �1 s 1! <br /> FILTER BED Wmrll O ft GTH DEPTH � ft <br /> j DISTANCE TO NEAREST WE ft OUNDATION ft PROPERTY LINE 7 ft <br /> 0 MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> D SUMPS WIDTH ft LENGTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 0 DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> (3 SEEPAGE PITS NumBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft 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 <br /> ORDINANCES,STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> M1 MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953-7697 <br /> SIGNEQTITLE DATE <br /> I <br /> I <br /> f / <br />{f <br /> 4 <br /> \ <br /> O,q <br /> C N O <br /> - - _ RT <br /> fEPARTMENT VSE QNLY <br /> Application Accepted 4K-1Date Area Employee ID# <br /> Final Inspection By to © SPECIAL PERMIT-Approved by <br /> Character of Soil to De h of 3 Ft: it/Su p Soil Character: <br /> COMMENTS <br /> PE SC Received eftrw Amount Permit/ <br /> Date Invoice# Permit ID# <br /> Code INFO By Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER PERMIT <br /> 05/30/2007 <br />