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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE-310 FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT , CALL 209 953-7697 FOR I%SPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESS Z7M3 CITY/ZIP- 1-4 <br /> CROSS STREET APNJQJ PARCEL SIZE Z p <br /> \ o <br /> OWNER! <br /> L PHONE Y+ <br /> OWNER ADDRESS 1/ \,p CITY/STATFJZIIs <br /> CONTRACTOR 1� I�.L7 <br /> PHONE <br /> CONTRACTOR ADDRESS CITY/STATF/ZIP <br /> LICENSE C-42 ❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft CEOGRAPHICALINFORMATION: Coordinates X V <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBEROF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG CAPACITY gal #OFCOMPARTMENTS_ <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL fi ft FOUNDATION .S•� R PROPERTY LINE M-1. R V' <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM)) C <br /> LEACH LINES X LEACHING CHAMBERSw[V� #OF LINES LENGTH OF LINES U 5 ft <br /> DISTANCE TO NEAREST WELL 1 + R FOUNDATION ft PROPERTY LINE it <br /> ❑ FILTER BED WIDTH R LENGTH ft DEPTH R <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ MOUNDED WIDTH R LENGTH ft DEPTH ft <br /> DISTANCETONF.ARF WELL-11 FOUNDATION ft PROPERTY LME R <br /> SUMPS WIDTH ft LE cjjr� DEPTH <br /> DISTANCE TO NEAREST WELL. FOUNDATION ft PROPERTY LINE R `\ <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH fl �N•J <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE R <br /> ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH R <br /> N DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE R <br /> f\n. <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 /> ` MI �wr NOTICE REQUIRED FOR 1.� � TIY)NS-PL 1.1.(209)953-7697 -710 <br /> SIGNE �\ r TITL DATE <br /> � L <br /> O I I I IC-- U IL I �[,L <br /> / <br /> O <br /> O <br /> ,L.iv+ <br /> h <br /> 0 0TgN ' <br /> LT P E <br /> DEPARTMENT USEONLY — - <br /> Application Accepted B Date G Area Employee IDN <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by I <br /> Character of Soil to Dep f 3 Ft: 'Pit/Sump Soil Character: <br /> COMMENTS!;) +1 oa _ I_ i <br /> PE I SC Received Chec Amount Date Permit/ Invoice# Permit IDN <br /> Code INFO B Remitted Service Re uest# <br />