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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT I l V <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT '1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM UATE ISSUE[ <br />SOB ADDRESS y�10 Aj y�/�V N CITY/ZIP % Gif�7 <br />CROSS STREET hJ9^J APN — �/ PARCEL SIZE <br />S OWNER NAME ///eLee't"' '* t/'2ri1Gd la1/lnI7lCY y�110 �J/r PHONE_ <br />OWNER ADDRESSCZI� �' _CITY/STATE/ZIP <br />CONTRACTOR 4nwx1 — ``l� _ �CljllL- PHONE �(e�"S,/D7r2 <br />CONTRACTOR ADDRESS ��b Mow D)C— —CITY/STATE/ZIP Zot ' «' <br />LICENSE ❑ 0�42 ❑FIC -36 OTHER NUMBER `LS7iA2 ySEXPIRATION DATE �I y <br />WATER TABLE DEPTH: �l) I �U' ft GEOGRAPHICAL INFORMATION: <br />❑ PERC TEST # BUILDING PERMIT # <br />TYPE OF WORK: NEW INSTALLATION U EPAIR/ DC <br />tes X <br />LAND USE APPLICATION #_ <br />I ENGINEER DE' <br />REPLACEMENT I OUT -OF -SERVICE SEPTIC SYSTEM LI DESTRUCTION <br />Y <br />D /ALTERNATIVE <br />INSTALLATION WILL SERVE: Yf- RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG __ 00elz <br />_ CAPACITY %/w <br />gal <br /># OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY <br />gal <br /># OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL �f ft <br />FOUNDATION _ <br />ft <br />PROPERTY LINE 40 ft <br />❑ LIFT STATION SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />�- LEACH LINES Cl LEACHING CHAMBERS <br /># OF LINES F LENGTH OF LINES SS <br />ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION '70 It PROPERTY LINE S5' <br />ft <br />❑ FILTER BED WIDTH __ ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft <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 ft PROPERTY LINE <br />ft <br />❑ SUMPS WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />Dom- SEEPAGE PITS NUMBER WIDTH %n" <br />ft DEPTH X257 f <br />ft <br />DISTANCE To NEAREST WELL__ ft <br />r <br />FOUNDATION ft PROPERTY LINE �J <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 />MINIMUM 24 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED <br />TITLE DATE %I'�n- <br />Application Accepted By �W14. <br />Final Inspection ByMk� <br />Character of Soil to Depth of 3 Ft: <br />Cr,RARAr4ITC <br />vrvnvi�i � i " <br />DOCPARTMENTAOSE 0NjLY <br />Date Area Employee ID# <br />Date ❑ SPECIAL PERMIT - Approved by <br />Pit/Sump Soil Character:C% / 4i -.IA ` <br />PE <br />SC <br />INFO <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/Code <br />Service Request # <br />Invoice # <br />Permit ID# <br />xv-/- <br />l l <br />a asi <br />S 9.�— <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />T <br />