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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-HEFUNDABLE F'ERMII <br />JOB ADDRESSJQ Id <br />(:ALLlUy `J9:f-/65/ FOR INSPECTIONS tXPIRES 1 YEAR FROOM DATE ISSUED <br />- CITY/ZIP 1 <br />CROSS STREET _ APN PARCEL SIZE 3 N C_ <br />OWNER NAME PHONEID v <br />OWNER ADDRESS > > CITY/STATE/ZIP - O <br />CONTRACTOR It i2,rin I PHONE �` �- '✓ <br />CONTRACTOR ADDRESS [`CITY/STATE/ZI phi <br />LICENSE 11C-42 1-1_ C-36 04_� / ^ �a NUMBER EXPIRATION DATE _ <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION I I REPAIR/ADDITION LI ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM 'Y�, DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />❑ GREASE TRAP <br />❑ LIFT STATION <br />TYPE/MFG <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />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 It <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />❑ LEACHING CHAMBERS <br />R ceiv <br />B <br />_ <br />_ # OF LINES <br />- c <br />Date <br />LENGTH OF LINES ft <br />- - <br />Invoice # <br />DISTANCE TO NEAREST <br />WELL <br />a <br />ft <br />FOUNDATION <br />4AmOLInt <br />2 <br />ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />It PROPERTY LINE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />1 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 />FOR INSPECTIONS - <br />TITLE DATE <br />DATE <br />DEPARTMENT USE ONLY Q <br />Application Accepted By ate. Area Employee ID#! 1 y1 /✓� <br />Final Inspection By a 11 SPECIAL PERMIT - Appro y <br />Character of Soil to De of 3 t Pit/Sump Soil Character: <br />COMMENTS G��''Irk^'"� 3 Gi m I. <br />, Ila1 <br />l <br />i/ , �ZmlL d ✓� S G� <br />P <br />Code <br />Sc <br />INFO <br />R ceiv <br />B <br />- <br />heck <br />ash <br />11 <br />itted <br />- c <br />Date <br />i <br />Permit/ <br />Service Reguest # <br />- - <br />Invoice # <br />Permit ID# <br />4�z ) <br />a <br />4AmOLInt <br />2 <br />2 kriW <br />I S 12002AY-0 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />J <br />