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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 SERMIT ALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITYIZIP � <br /> CROSS STREET w' APN V PARCEL SIZE <br /> OWNER NAME 2 c !'Qr�JY��t G j c L-�(,yrA` p Lod.-PHONE <br /> / n <br /> OWNER ADDRESS �v S. t' t l J 1`V e CITYISTATE/ZIP/j w U}- I f `" A qS a" v <br /> CONTRACTOR ,/ PHONE <br /> CONTRACTOR ADDRESS �>��+'� 1/!/V fr CITYISTATE/ZIP_,,,� <br /> LICENSE 00C42 ❑OC-36 JyOTHER l--I NUMBER_' C✓, EXPIRATION DATE <br /> WATER TABLE DEPTH: w ft GEOGRAPHICAL INFORMATION: Coordinates; X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: "If NEW INSTALLATION REPAIRIADDITION 4. ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: ! RESIDENCE U COMMERCIAL) CJ OTHER <br /> NUMBER OF LIVING UNITS: + NUMBER OF BEDROOMS: 1 NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG CAPACITY J�76r) gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST. WELL /15L2 4 It FOUNDATION /. 7 ft PROPERTY LINE �— <br /> /�.❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> VV <br /> V LEACH LINES 0 LEACHING CHAMBERS � #OF LINES LENGTH OF LINES ft <br /> .� <br /> DISTANCE TO NEAREST WELL / it FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH It DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE it <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NE2rT WELL ft ROUNDATION ft PROPERTY LIQ�_ft <br /> SEEPAGE PITS NumsER WIDTH / �r ft DEPTH ft <br /> r <br /> DISTANCE TO NEAREST WELL� ZZ�ft FOUNDATION 3. ft PROPERTY LINE ��ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN�C <br /> ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> NOTICE REQUIRED FOR INSUCrIONS-PLEASE CALL 1209)9,53-769 <br /> SIGNED TITLE DATE <br /> DEPARTMENTUSE Ota <br /> y L.� ��1� <br /> Application Accepted Date L —)1. Area 10 Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Amount Date Permit! Invoice# Permit ID* <br /> Code INFO B Cash Remitted -Service Relluest# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14118 <br />