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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT Pv/, <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />` <br />NON-REFUNDABLE PERMIT c J CALL 209 953-7697 FOR INSPECTIONS <br />+ EXPIRES 1 YEAR FROM DATE ISSUE[ <br />JOB ADDRESS 1 1 �' J G ]e�1t ,5� _ - - CITY/ZIPTc4u% t.� r2 1� Z' J <br />y� Q <br />`I CROSS STREET ` t C- K) 11 fey 91D APN 10 -Q ID - O{D PARCEL SIZE <br />�i <br />OWNER NAME ty -ilGl� d i -�_>419,5e- yJ PHONE 6qq - f SC <br />OWNER ADDRESS �� ��Kh C+ CITY/STATE/ZIP �' 1 CIA Jac Nom-✓' 1 .��% <br />CONTRACTOR on ('rLtf S .6 PHONE PHONE — JP[ <br />CONTRACTOR ADDRESS _101 k 0'-w 6 �� _ CITY/STATE/ZIP01" 443rD <br />LICENSE ❑' C-42 ❑' iC-36 OTHER NUMBER4as s__5kj -EXPIRATION DATE <br />-!_.. .1 <br />WATER TABLE DEPTH: �:10 � Li tt GEOGRAPHICAL INFORMATION: GOOrainateS A _ T <br />Cl PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: i NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE I I COMMERCIAL OTHER <br />NUMBER OF LIVING UNITS: ( NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />DISTANCE TO NEAREST: WELL It <br />❑ LIFT STATION SIZE TYPE OF PUMP <br />CAPACITY gal # OF COMPARTMENTS <br />CAPACITY gal # OF COMPARTMENTS <br />FOUNDATION ft PROPERTY LINE ft <br />❑ PKG TX PLANT U SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES ❑ LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />G7,"'FILTER BED WIDTH It LENGTH �J ( <br />ft DEPTH -1 8f' It <br />DISTANCE TO NEAREST WELL ra ., P It <br />FOUNDATION ft PROPERTY LINE ),�e� ft <br />El MOUNDED WIDTH _ ft LENGTH <br />ft DEPTH , ' at <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS WIDTH ft LENGTH <br />ft DEPTH <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE #js <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH nPcp ? <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION _ft PROPERTY LINE ft <br />❑ SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH iii" It <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE It <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND <br />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 ?4 HOUR ADVANCE NOTICE REQUIRED <br />FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED _ <br />TITLE G^g ": 0' C;d�0 -__ DATE <br />DEPARTMENTUS ONLY y, <br />Application Accepted B `�_ Date _ Area ' I Employee ID# "&49 <br />Au <br />Final Inspection By iI Date_ ❑ SPE IAL PERK]"` IT Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: N /64-1 <br />COMMENTS 7i LL71- L&A/AAL-7t 'li __ <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit! <br />Service Request # <br />Invoice # <br />Permit ID# <br />42-01 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />#A- <br />