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ONSITE WASTEWATER TREA1..MENT SYSTEM PERMIT f/ <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />•NON-REFUNDABLE PERM z <br />7 � GALL(ZUJ 953-7697 FOR INSPECTIONS tXPIRES 1 YEAR FROM UATE ISSUE <br />ZI <br />JOB ADDRESS l/ - CITYJ/�ZIP _ )_' 5i::;'33zz <br />' CROSS STREET 0161 G APNj[ v'`�n _ _ AR EL SIZE <br />OWNER NAME Cl/L" cz ____ ___ _ PHON /C✓� / <br />1 C <br />OWNER ADDRESS p yE ! \ _ _ _ CITY/STATE/ZIP 0W1.41 <br />CONTRACTOR,, PHONE <br />^ r. <br />_ CITY/STATE/ZIP �--+�' �/ <br />CONTRACTOR ADDRESS G" <br />LICENSE ❑ IC -42 ❑ C-36 OTHER 1 NUMBER Z/ [ 7EXPIRATION DATE <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X _ .. Y <br />1-1 PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION i i REPAIR/ADDITION ENGINEER DESIGNED/ TE NATIVE <br />REPLACEMENT [I OUT -OF -SERVICE SEPTIC SYSTEM 1,C, DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE <br />❑ COMMERCIAL <br />I I OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />„1 -0 -11 -SEPTIC TANK TYPE/MFG _ _ <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />It PROPERTY LINE It <br />❑ LIFT STATION SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES ❑ LEACHING CHAMBERS - <br /># OF LINES <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE It <br />❑ FILTER BED WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS WIDTH It LENGTH _. <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH _ __ ft LENGTH <br />ft <br />DEP'IH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE It <br />❑ SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS. I ALSO CERTIFY <br />THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATLON LAWS. <br />IvlIIV1IVIUIVI L n /v C llI fLoc r1CWUInCU rur-1 IIvJrCI+ 1IV/v17 ' rLGNJG t.r+�a. cva a✓.�-1 1 <br />SIGNED _ . _ TITLE CiN /`Qs DATE <br />T <br />N <br />7Q� <br />tr <br />p z H <br />VWQ <br />5 Z W <br />pOo <br />sC�2 <br />�W <br />AV EPARTMENT IJSEIONLY ✓ �M <br />Application Accepted y Date Area J Employee ID# �%// <br />4 <br />Final Inspection By Date Z' / ❑ SP CIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: _ Pit/Sump Soil Character: <br />COMMENTS _. <br />Permit/ <br />-- <br />PE <br />SC <br />INFO <br />Received <br />B <br />Check#/ <br />Cash <br />ount <br />AmPermit/Code <br />Remitted <br />Date <br />Service Request # <br />Invoice # <br />Permit ID# <br />21�� <br />( <br />Cy7S Z)Le� f� <br />�]� <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />