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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 />N.!JN-REFUNDABLE PERWT,, CALL209 953-7697 FOR INSPECTIONS EXPI ES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESSTiala-0. *Avfl CITY/ZIP 7 <br />CROSS STREET 4C -1171W V 47- APV11M, — f'l/ - 77k) , PARCEL SIZE <br />OWNERNAME /ZGLO��S • PHONE <br />/ O Q"4 --r f IP <br />OWNER ADDRESS <br />I/ � CITY/STATE/ZIP p /'� �/ ✓� <br />CONTRACTOR •G• I�/��f IVC .% _ PHONE <br />CONTRACTOR ADDRESS PO 8OI' `� CITY/STATE/ZIP <br />LICENSE I I C-42 I J C-36 OTHER — / NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION <br />1_1 PERC TEST # BUILDING PERMIT # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADI <br />Coordinates X Y <br />LAND USE APPLICATION #— <br />)N ENGINEER DESII <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM X DESTRUCTION <br />D/ALTERNA <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />Of NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />5r SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY <br />CAPACITY <br />DISTANCE TO NEAREST: WELL ft FOUNDATION <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ 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 LEACHING CHAMBERS # OF LINES <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ FILTER BED WIDTH _ ft LENGTH _ ft <br />DEPTH _ ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED WIDTH ft LENGTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS WIDTH ft LENGTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE 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 />MI UM OTICE REQUIRED FOR INSPECTIONS - <br />gVASE CALL 209 953- 697 <br />SIGNED TITLE ��4 �� <br />�'�� DATE <br />Application Accepted By V <br />Final Inspection By <br />Character of Soil to Dep of <br />COMMENTSG6-�I,C— <br />DEPARTMENT PSE U(Nl,,Y <br />—� Date Area Employee ID <br />Date_ ❑ SPECIAL PE MIT - Approved by <br />Pit/Sump Soil Character: <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />h <br />ash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />ku(�2 <br />1 2(c I <br />S(zb0--tyi-cl i <br />42-01 <br />5/5/17 <br />N e to - <br />-'K <br />S'4e <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />