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i <br /> i" <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> j J08 ADDRESS <br /> CROSS STREET ___._._. APN _—_PARCEL SIZE <br /> j OWNER NAME _PHONE J' <br /> i .. <br /> OWNER ADDRESS __________ _____CRY/STATE/ZIP <br /> CONTRACTOR _____—._ -- _-_ .--PHONE <br /> i <br /> i CONTRACTOR ADDRESS ________ CITY/STATF/ZIP <br /> i <br /> e� <br /> LICENSE ❑rAC-36 OTHER NUMnEn___„_-___ EXPIRATION DATE ------ <br /> I _ <br /> WATER TABLE DEPTH: __it GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT If- �,-__ _ LAND USE APPLICATION# <br /> TYPE OF WORK: 0 NEW INSTALLATION i I REPAIR/ADOITION 0 ENGINEER DESIGNED/ALTERNATIVE <br /> !I REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM U DESTRUCTION <br /> I INSTALLATION WILL SERVE: ❑ RESIDENCE LI COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS' NUMBER Of BEDROOMS:_ NUMBER OF EMPLOYEES: <br /> e. Q SEPTIC TANK TYPEIMFG CAPACITY gal If OF COMPARTMENTS <br /> Q GREASE TRAP TYPE/MFG ___.__ CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL _ it FOUNDATION it PROPERTY LINE it <br /> C) LIFT STATION SIZE TYPE OF PUMP --_❑ PKG TX PLANT 0 SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> G LEACH LINES 11 LEACHING CHAMBERS_— #OF LINES LENGTH OF LINES it <br /> DISTANCE TO NEAR EST WELL__,_.___.._._ ft FOUNDATION it PROPERTY LINE it <br /> Q FILTER BED WIDTH --_it LENGTH it DEPTH it <br /> DISTANCE TO NEAREST WELL___,__.__.-_.-._. R FOUNDATION _..it PROPERTY LINE _it <br /> Q MOUNDED WIDTH it LENGTH it DEPTH PA. -- it <br /> DISTANCE To NEAREST WELL ____.it FOUNDATION ..it PROPERTY LINE._ <br /> Q SUMPS WIDTH it LENGTH it DEPTH <br /> DISTANCE TO NEAREST WELL _it FOUNDATION---it PROPERTY _ .7_Zs�it <br /> Cl DISPOSAL PONDS WIDTH it LENGTH it DEPTH L(J��it <br /> DISTANCE TO NEAREST WELL __- it FOUNDATION ____-____._it PROPERTYN_ <br /> Q SEEPAGE PITS NUMBER WIDTH ____ it. DEPTH <br /> DISTANCE TO NEAREST WELL ___ it FOUNDATION it PROPERTY LINE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAOUIN COUNTY. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> r. SIGNED _ TITLE - DATE <br /> Hill <br /> I• I <br /> DEPARTMENTUSE ONLY <br /> Application Accepted By DateArea _ Employee ID# <br /> Final Inspection By ____ Date,_,__ ❑ SPECIAL PERMIT-Approved by <br /> Pit/Sump Character of Soil to Depth of 3 Ft: —__ P Soil Character: <br /> COMMENTS ------------ <br /> _ -- <br /> PE SC Received Check#/ Amount Date Permit/ Invoice a Permit ID# <br />