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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 PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIREES' /1 YEAR FROM DATE ISSUED <br />JOB ADDRESS (� G- J/n — , C/IeT�Y/ZIP�'^�, ��(�% ���// �y %�(��Q� <br />CROSS STREET rR? �.� �X APN�14 a? zJ V PARCEL SIZE <br />OWNER NAME _ '-� PHONE_ #_ <br />OWNER ADDRESS 7 l v CITY/STATE/ZIP (LL�b�YI , ��( �js '4 <br />CONTRACTOR <br />CONTRACTOR <br />CITY/STATE/ZIP <br />LICENSE ❑0C-42 ❑11C-36 OTHER L� Z NUMBER %t— EXPIRATION DATE LUL.1 <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: COOrdlnateS X <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEER DI <br />❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL <br />NUMBER OF LIVING UNITS: / NUMBER OF BEDROOMS: <br />❑ SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />❑ LIFT STATION <br />CAPACITY <br />CAPACITY <br />DISTANCE TO NEAREST: WELL ft FOUNDATION <br />SIZE TYPE OF PUMP ❑ PKG TX PLANT <br />Y <br />OTHER <br />NUMBER OF EMPLOYEES: <br />/ALTERNATIVE <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES ❑ LEACHING CHAMBERS # of LINES LENGTH OF LINES <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />❑ FILTER BED WIDTH ft LENGTH ft DEPTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />❑ MOUNDED WIDTH ft LENGTH ft DEPTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />L3SUMPS WIDTH ft LENGTH ft DEPTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED [ /'/ � TITLE iZ/%?' foebj2 � DATE'%��i�Z� y <br />Application Accepted <br />Final Inspection By� <br />Character of Soil to D <br />COMMENTS <br />nf'2 Ft• <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />DEPARTMEN US ONLY C ,, / ,,yENT <br />Date Area7r �" Employee ID# ,� I/L----� <br />Date �Z ❑ SP IAL PERMIT -Approved by <br />Pit/Rmmn Rnil Rhnrnrtnr• <br />PE <br />SC <br />Received <br />Ic#/ <br />Amount <br />Date <br />Permit/ <br />Invoice # <br />Permit ID# <br />Code <br />INFO <br />B <br />Cash <br />Remirtted <br />Service Request # <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERM' <br />4/14!16 <br />