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It 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 95 -7697 FOR INSPECTIONS E PIR S 1 YEAR FROM DATE ISSUE <br />V. <br />JOB ADDRESS CITY/ZIP <br />CROSS STREET I APN �c �/ PARCEL SIZE D ' <br />OWNER NAM 10D I GIM PHONE 06 <br />OWNER ADDRESS �al LN CITY/STATE/ZIP zi <br />CONTRACTOR N PHONE G� <br />CONTRACTOR ADDRESS /I rIQ CITY/STATE/ZIP ?/ C <br />LICENSE 1� C-42 1111C-36 OTHER—,—) NUMBEf� EXPIRATION DATEy ^i 3 / <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X _ _ Y <br />❑ PERC TEST # BUILDING PERMIT # _ LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED <br />REPLACEMENT I OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTIO <br />INSTALLATION WILL SERVE: ❑ RESIDENCE U COMMERCIAL LI OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: _ <br />❑ SEPTIC TANK <br />❑ GREASE TRAP <br />❑ LIFT STATION <br />TYPE/MFG <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />SIZE TYPE OF PUMP <br />CAPACITY <br />CAPACITY <br />ft FOUNDATION <br />❑ PKG TX PLANT <br />9 <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />LEACHING CHAMBERS <br />CheaW <br />Amount <br /># OF LINES <br />Permit/ <br />LENGTH OF LINES <br />ft <br />Code <br />DISTANCE TO NEAREST <br />WELL <br />Remitted <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />007 1& <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />It <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />It <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SUMPS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS <br />WIDTH <br />It <br />LENGTH <br />ft <br />DEPTH <br />It <br />DISTANCE TO NEAREST <br />WELL <br />It <br />FOUNDATION <br />ft PROPERTY LINE <br />It <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH <br />It <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />_ <br />It PROPERTY LINE <br />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 REGULATIONS. I ALSO CERTIFY 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 COMPENSATION LAWS. <br />wei►tXs7 <br />Application Accepted <br />Final Inspection ByC <br />Character of Soil to D <br />COMMENTS 94 <br />-PLEASE <br />TITLE CK�t n DATE <br />_�— <br />DEPARTMENT Uw OJVLY <br />Date Area3111?qEmployee ID# avfm <br />Date ❑ SPECIAL P RMIT - Approved by <br />Pit/ mp Soil Character: <br />q, M7,273 <br />L 6n� .0j__ nr.�,...�,.._ �e .� T�9NA ����.� J \\U <br />PE <br />SC Received <br />CheaW <br />Amount <br />Date <br />Permit/ <br />Invoice # <br />Permit ID# <br />Code <br />INFO B <br />ash <br />Remitted <br />Service Request # <br />g0 <br />1 4t <br />007 1& <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />