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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-REFUN ABL P,EMW <br />CALL 209 953-7697 FOR INSPECTION4 <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CITY/ZIP <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />CROSS STREET <br />n' <br />APN�©7l l <br />PARCEL SIZE <br />ft DEPTH <br />3 <br />PHONE2oC— m <br />OWNER NAME <br />ft <br />CiOWNER <br />ADDRESS <br />CITY/ST %TE/ZIP <br />ft PROPERTY LINE <br />41 <br />O <br />CONTRACTOR <br />PHONE <br />DISTANCE TO NEAREST WELL c� ft FOUNDATION <br />4 ft PROPERTY LINE } <br />Wjj:SAtj <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />CONTRACTOR ADDRESS <br />t CITY/STATE/ZIP <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />LICENSE X, iC-42 ❑ IC -36 OTHER <br />NUMBER t _oml EXPIRATION DATE Ldlq- <br />WATER TABLE DEPTH: <br />It GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />❑ PERC TEST # <br />BUILDING PERMIT # LAND USE APPLICATION # M4�.. <br />TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION <br />ENGINEER DESI tt um7fiva <br />_I REPLACEMENT I I OUT -OF -SERVICE SEPTIC SYSTEM <br />DESTRUCTION iY d <br />INSTALLATION WILL SERVE: <br />RESIDENCE ❑ COMMERCIAL <br />❑ OTHER <br />NUMBER OF LIVING UNITS: <br />NUMBER OF BEDROOMS: <br />NUMBER OF EM <br />❑ SEPTIC TANK TYPE/MFG <br />CAPACITY <br />AEI►�S,:, <br />gal # OF CQ A7tIf�(U1m119� COTU� <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY <br />gal # OF COMPALRTTIMJETti'S`1`'�RTe_ <br />DISTANCE To NEAREST: WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE <br />TYPE OF PUMP ❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />24 At <br />Id LEACH LINES v( LEACHING CHAMBERS � # OF LINES LENGTH OF LINES - _ <br />ft <br />Received <br />BV <br />h <br />Cash <br />Amount <br />Remitted <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE E <br />ft <br />❑ FILTER BED WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ MOUNDED WIDTH ft LENGTH <br />It DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />J�! SUMPS WIDTH It LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL c� ft FOUNDATION <br />4 ft PROPERTY LINE } <br />ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH <br />It <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft 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. <br />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 />Application Accepted By ILI <br />Final Inspection By <br />Character of Soil to Depth of 3 F <br />COMMENTS Sxi Oy" <br />Area -W-q_ Employee ID# <br />❑ SPECIAL PERMIT - Approved by <br />PE <br />Code <br />SC <br />INFO <br />Received <br />BV <br />h <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />s?�7 <br />12n f80($�ct�� <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />