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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT fl � <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON -REFUND B P IT CAL 20 953.7697 FOR INSPECTIO ES EAM4QM q0,'E '*I'L1J$ <br />1 1)JOB ADDRESS c _ _ CITY/ZIP< <br />1 <br />CROSS STREET APN� PARCEL SIZE <br />OWNER NAME 449; 3. �\ __=( <br />OWNER ADDRESS- o3 �P <br />CONTRACTOR <br />CONTRACTOR ADDRESS 6o ILS <br />LICENSE q C-42 il C-36 OTHER <br />WATER TABLE DEPTH: <br />1 3 Vy CITY/STATE/ZIP <br />PHONE %/ ✓ <br />I� sT7, <br />�/�v��l��/�J CITY/STATE/ZIP <br />NUMBEN�� ! EXPIRATION DATE_ �tt <br />ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />CI PERC TEST # <br />LENGTH OF LINES <br />ft <br />BUILDING PERMIT # <br />ft PROPERTY LINE <br />LAND USE APPLICATION # <br />❑ FILTER BED WIDTH ft LENGTH <br />TYPE OF WORK: <br />1 1 NEW INSTALLATION LI <br />REPAIR/ADDITION <br />ENGINEER DESIGNED/ALTERNATIVE <br />ft <br />REPLACEMENT 11 <br />OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE <br />Ll COMMERCIAL <br />I i OTHER <br />ft <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />ft <br />SEPTIC TANK <br />TYPE/MFG �. <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />ft <br />❑ SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE _ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />0 PKG TX PLANT <br />O SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES ❑ LEACHING CHAMBERS # OF LINES <br />LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ FILTER BED WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ MOUNDED WIDTH _ ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SUMPS WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH _ <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK <br />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 <br />AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MI 4 H T E REQUIRED FO TI <br />- LEASE CALL 209 9 3-7 7� <br />SIGNED&UL— TITL <br />— DATE r <br />Application Accepted <br />Final Inspection By <br />Character of Soil to Depth of 3 Ft: <br />COMMENTS <br />cPARTMEN' T SE O ILY H6ALIri TTAL <br />Date _ __ Area Employee ID# NTS <br />�_. Date _� Li SPECIAL PERMIT - Approved by <br />it ump Soil Character...., <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Check <br />ash <br />Amount <br />emi a <br />Date <br />PermiU <br />Service Request # <br />Invoice # <br />Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />47 <br />vl <br />