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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT �_3 -3 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFI,NDABLE PERMIT, CALL (209) 953-7697 FPR INSPECTIONS I. XPIRES 1 YEAR FROM DATE ISSUED <br />JO& ADDRESS (7 ( —I <br />Y [� <br />..r lam\ CITY/ZIPG is°I/� w y, <br />'>`510 fz <br />CROSS STREET <br />�7�G <br />APN /o' � � <br />7 / <br />PARCEL SIZE 7 • ��j <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />OWNER NAME <br />SEPTICTANK TYPE/MFG <br />PHONE <br />q/ <br />OWNER ADDRESS"/ li <br />FJYI/D�/1`v <br />�KQ/ CITY/STATE/ZIP <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />CONTRACTOR /epxr <br />%� <br />PHONE 7 J <br />❑ FILTER BED WIDTH <br />CONTRACTOR ADDRESS <br />y� yS <br />'.f T /�1°.e%y� <br />�7� ��C✓ <br />❑ <br />OTHER <br />'_CITY/STATE/ZIP <br />NUMBER �EXPIRATION DATE2 <br />s/,p/'�j <br />LICENSE IC 42 IC -36 <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH _ <br />ft LENGTH ft DEPTH ft <br />t <br />WELL ft FOUNDATION ft PROPERTY LINE ft <br />A( SEEPAGE PITS NUMBER <br />WATER TABLE DEPTH: 1 I O 7 J ft <br />GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING <br />PERMIT # AND USE AP PLICATION # <br />TYPE OF WORK: NEW INSTALLATION <br />I_I R PAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT <br />I OUT -OF -SERVICE SEPTIC SYSTEM I DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: <br />NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />SEPTICTANK TYPE/MFG <br />�y - <br />yam L� CAPACITY !Z= DOD gal #OFCOMPARTMENTS L/ <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: <br />WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />JIL LEACH LINES ❑ LEACHING CHAMBERS # OF LINES LENGTH OF LINES 7 S ft <br />DISTANCE TO NEAREST <br />1 , <br />WELL ft FOUNDATION SID -, ft PROPERTY LINE ft <br />❑ FILTER BED WIDTH <br />ft LENGTH _ ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED WIDTH <br />ft LENGTH ft DEPTH ft <br />DISTANCE TO NEARE=ST <br />WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS WIDTH <br />ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH _ <br />ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION ft PROPERTY LINE ft <br />A( SEEPAGE PITS NUMBER <br />WIDTHft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION 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, <br />AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA <br />CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIM 24 HOUR ADV CE <br />UeIFCE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED 2 <br />_ TITLE DATE <br />Application Accepted <br />Final Inspection By <br />Character of Soil to D <br />COMMENTS _105 <br />DEPARTMENT ISEE g2NLLY' <br />3 Date (_�_ Area _L4V1 Employee ID#_� <br />Date ( ❑ SPECIAL PERMIT - Approved by <br />pt <br />h of 3 Ft: Pit/Sump Soil Character: "AA wr <br />b <br />PE <br />Code <br />SC <br />INFO <br />Received <br />Chec <br />ash <br />Amount <br />emitted <br />Permit/ <br />mate Service Request # <br />Invoice # <br />Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />rA <br />