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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 <br />JOB ADDRESS Z <br />CROSS STREET <br />OWNER NAME L <br />OWNER ADDRESS �0 / •` <br />CONTRACTOR t/ <br />CONTRACTOR ADDRESS _ zt_/V 1 <br />L 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DAT <br />E ISSUEI <br />CITY/ZIP -� G <br />A P N a tC�6 PARCEL SIZE <br />PHONE tl / -3--/ /DTZ / <br />_CITY/STATE/ZIP <br />LICENSE I I C-42 I I C-36 OTHER NUMBERS_ZYS'_?EXPIRATION <br />WATER TABLE DEPTH:, �6� ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />1 PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESI N /ALTERN IV <br />X REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM { DESTRUCTION <br />INSTALLATION WILL SERVE: A RESIDENCE ; I COMMERCIAL L. OTHER <br />NUMBER OF LIVING UNITS: / NUMBER OF BEDROOMS: _? NUMBER OF EMPLOYEES: <br />7 <br />® SEPTIC TANK TYPE/MFG �/ 4 �/t�C/G <br />CAPACITY C2 gal # OF COMPARTMENTS ' Z- <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ��� t ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL It <br />FOUNDATION ft PROPERTY LINE ft <br />© FILTER BED WIDTH / _? It LENGTH `L <br />/ ft DEPTH ft <br />Z <br />1406 kt DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH ft <br />DISTANCE To NEAREST WELL ft <br />FOUNDATION 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 />MINIMUM 24 R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED _ <br />TITLE DATE . —/ 2- `r ,4P' <br />Application Accepted <br />Final Inspection By-) <br />Character of Soil to D <br />COMMENTS <br />pth of 3 Ft: <br />Date <br />Y <br />Area Employee ID#� <br />❑ SPECIAL PERMIT - Approved by <br />Soil Character: <br />PE <br />CodeINFO <br />SC <br />Received <br />B <br />jdfiecW <br />as <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />+ <br />� <br />lz <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />rn <br />