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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P -"4 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NQN-HEFUP <br />J03 ADDRESS <br />f„ROSS STREET _ <br />OWNER NAME <br />OWNER ADDRESS <br />PERMIT <br />953-7697 FOR INSPECTIONS EXPIRES 1 YEAR <br />FROM CUATE ISSUEI <br />CITY/ZIP <br />CONTRACTOR �����/(1 /Z �L ��Z /,we—/ PHONE <br />�d 3 7 <br />CONTRACTOR ADDRESS 5 �—� CITY/STATE/ZIP' <br />LICENSE ❑ IC -42 11 'C-36 OTHER / 1 4: 02' NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: _ ft GEOGRAPHICAL INFORMATION: Coordinates X - Y <br />_i PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM r�iB�STRUCTION ” C' n <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL I 1 OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />0< SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />❑ LIFT STATION SIZE TYPE OF PUMP <br />_ CAPACITY <br />CAPACITY <br />ft FOUNDATION <br />❑ PKG TX PLANT <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES D LEACHING CHAMBERS # OF LINES <br />LENGTH OF LINES <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />❑ FILTER BED WIDTH ft LENGTH <br />ft DEPTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />❑ MOUNDED WIDTH ft LENGTH <br />ft DEPTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />❑ SUMPS WIDTH ft LENGTH <br />ft DEPTH <br />DISTANCE TO NEAREST WELL It FOUNDATION <br />ft PROPERTY LINE <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />❑ SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <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 <br />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 />MINIM DVAKE NOTICE REQUIRED FOR INS ECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED Al",,TITLE N C O '' ` DATE <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />DEPA RITMENT SOWL <br />Application Accepted By Date 4y AreaEmployee ID# <br />Final Inspection By �� Date tVitStjrnp <br />_�_ ❑ SP CIAL PERMIT - Approved by ����� <br />Character of Soil to Depth of 3 Ft: Soil Character: <br />COMMENTS <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />( <br />6 P -c7 <br />2ti. -- <br />15906 7 D <br />42-01 <br />5/5/17 <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />T <br />