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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 (2091953-7697 FOR INSPECTIONS _EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CROSS STREET <br />. Ael <br />CITY21P 1.S/0 <br />APN 1 t33g0oI <br />3 <br />PARCEL SIZE q. S i - <br />OWNER NAME <br />i; Ci <br />V U h h S A O <br />DISTANCE TO NEAREST WELL ft <br />OWNER ADDRESS <br />I ( <br />5. / r G V le <br />_�dPPHHO,N�^E��Q � 7 _ <br />_ CITY/STATE/ZIP �� O <br />CONTRACTOR <br />t,( _a <br />oe 'Al <br />- <br />�.jCG _ PHONE <br />CONTRACTOR ADDRESS <br />��� ���1T Li%'% /'"-b CITY/STATE/ZIP <br />LICENSE �k C-42 <br />❑ 'C-36 <br />OTHER 4 <br />NUMBER EXPIRATION DATE <br />I � <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: COOT I <br />inates X Y <br />Ll PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: A4.1 NEW INSTALLATION LI R PAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT 1 OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: �ESIDENCE ❑ COMMERCIAL OTHER <br />NUMBER OF LIVING UNITS:` NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br />SEPTIC TANK TYPE/MFG v v CAPACITY _ gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG h CAPACITY / gal # OF COMPARTMENTS <br />f� <br />DISTANCE TO NEAREST: WELL <br />r/U� It FOUNDATION t7� ft PROPERTY LINE 7 ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />XLEACH LINES F� LEACHING CHAMBERS <br />, <br /># OF LINES LENGTH OF LINES J, <br />ft <br />DISTANCE TO NEAREST WELL ft <br />// <br />FOUNDATION ft PROPERTY LINE S� <br />ft <br />❑ FILTER BED WIDTH ft LENGTH <br />It DEPTH <br />ft <br />DISTANCE TO NEAREST WELL It <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ MOUNDED WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION It PROPERTY LINE <br />ft <br />❑ SUMPS WIDTH ft LENGTH <br />It DEPTH <br />ft <br />DISTANCE TO NEAREST WELL It <br />FOUNDATION It PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL It <br />FOUN ATION ft PROPERTY LINE <br />ft <br />SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH , 1 <br />ft <br />DISTANCE To NEAREST WELL ft <br />FOUNDATION "4d ft PROPERTY LINE ' i <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 />MINIM19f 24 HOUR ADVANC _ NOTICE REQUIRED <br />FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED �_ _ .._ T <br />TITLE _ DATE <br />Application Accepted By[_��/fH� <br />Final Inspection By=/(`el/S�CLN^ <br />Character of Soil to Depth of 9 Ft: G <br />COMMENTS el/4.IYr <br />Date <br />lS NL <br />Area � Employee ID#Won 0 <br />r <br />7 ❑ SPECIAL PERMIT - Ap roved b <br />Pit/Sump Soil Character: d<;Iov <br />PE <br />SC <br />Received Check#/ <br />Amount <br />Date <br />Permit/ <br />Invoice # <br />Permit ID# <br />Code <br />INFO <br />B Cash <br />Remitted <br />Service Request # <br />�g <br />L <br />is <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />rn <br />