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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT V' <br />CAPACITY gal # OF COMPARTMENTS <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL <br />209 953-7697 FOR INSPECTIONS// EXPII►RES 1 YEAR FROM <br />DATE ISSUED <br />JOB ADDRESS <br />, <br />CITY/Z`IPa1, � � C.�;° <br />L w <br />CROSS STREET Lo 4� <br />f <br />/� ff <br />APN ( 01 1 1 0 ` 1 PARCEL SIZE <br />I ` <br />'OWNERNAME i�( ,6:.t ]sefl L``�+ <br />I�'q PHONE <br />FOUNDATION ft PROPERTY LINE ft <br />1�!� �L <br />OWNER ADDRESS �j�t tLS.1.} <br />P(-- ITY/STATE/ZIP <br />7�7 <br />CONTRACTOR !S J 1�tW�, �sCK4 <br />^ <br />��� �(� PHONE <br />ft DEPTH <br />CONTRACTOR ADDRESS �67(R�C1 <br />CITY/STATE/ZIP�IItT�t� <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />LICENSE ❑❑C-42 I I C-36 OTHER <br />NUMBER EXPIRATION DATE <br />FOUNDATION ft PROPERTY hI �N�/�N�, ft <br />�9�Ty <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />l PERC TEST # BUILDING PERMIT # _ LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: L RESIDENCE I COMMERCIAL OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />TERNATIVE <br />❑ SEPTIC TANK TYPE/MFG _ <br />CAPACITY gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />P.-�LEACH LINES LEACHING CHAMBERS <br />.._.... .... <br /># OF LINES _- LENGTH OF LINES 490 ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION 161 ft PROPERTY LINE �,i' ft <br />❑ FILTER BED WIDTH ft LENGTH <br />ft DEPTH ft <br />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 lit <br />❑ SUMPS WIDTH ft LENGTH <br />ft DEPTH <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE NAP t <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH SAA, ._ %/%fn ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY hI �N�/�N�, ft <br />�9�Ty <br />❑ SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH NQr_ EM�VN 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED <br />TITLE DATE <br />DEPARTM NT USE ONLY pp <br />Application Accepted By ` Date Z $ Area b1hih. Employee ID# 1y <br />Final Inspection By SJ-sw Date ❑ SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft:U Pit/Sump Soil Character: <br />COMMENTS (Ze CY w -&-A14 Lc Y f7�ro� 6 <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />ec <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />z 10 <br />- <br />l7`Ib <br />2 �3 <br />5i22167 --z <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />