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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE,-3v°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDA E PERM] CALL 209 53-7697 FOR INSPECTIONS AXPIRS I YEAR FRqV 0AXIFjSSLED <br /> CITY/ZI / <br /> JOB ADDRESS I <br /> CROSS STREET APN C77-2Z'� PARCEL SILT J�— o <br /> 9► 9 3 I- 1-74-S A <br /> OWNER NAME �I PHONE <br /> OWNERADDRESS WE A 1r I CITY/STATE/ZIP <br /> CONTRACTOR v SOI v Y�G PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-42 LJ C-36 OTHER NUMBER AftMff_ EXPIRATION DATE <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# _ LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE./MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ CREASE TRAP TYPF/MFG CAPACITY gal #OF COMPARTMENTS 1� <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL - ft FOUNDATION ft PROPERTY LME ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM)ttttt <br /> LEACH LINES �LEACHING CHAMBER CS #of LINES�_ LENGTH of LINES ft <br /> DISTANCE ToNEAREST WELL A FOUNDATION It PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE.TO NEAREST WELL fl FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH Il <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDT1i ft LENGTH ft DEPTH R <br /> 1. DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH R <br /> DISTANCE TO NEARES WELL ft FOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER WIDTH -1 111 DEPTH ft I1�` <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> `/nl'/,/`�' <br /> tCM='CF <br /> ORDINANSTATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> (�\�`"' `�-�MII�N7REQUIRED FOR IN. NS-P 'C LL(209)953-7697 5 <br /> SIGNED V TITL DATE. <br /> T <br /> POT 19 IrD <br /> a u/ <br /> O Q � (7. <br /> Mill I <br /> VDEPARTME�T U. ON' Jr ZApplication Acceptedted B Date Area 12 Employee ID# -Final Inspection B Date �� li ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to De h of 3 Ft: <br /> Pit/Sump Soil Character. <br /> COMMENTS <br /> PE SC Received ec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Re uest# <br />