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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 (:ALL 2(J9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE <br />JOB ADDRESS -6- L O G C CITY/ZIP �S $ G <br />�S(:Atib'�✓ , <br />CROSS STREET rlGnc APN�t)6o -o3 PARCEL SIZE <br />OWNER NAME PHONE <br />OWNER ADDRESS y 9 f 8 L on e e CITY/STATE/ZIP /5J C4/ -o4 �lC <br />CONTRACTOR �S PHONE 1 7f -- b113 5/Z <br />CONTRACTOR ADDRFSS / j�9 !,'w2 CITY/STATF/71P F��%f �E /,I' . LL( /J jw <br />LICENSE IVC -42 ❑FC -36 OTHER NUMBER �0 EXPIRATION DATE <br />� 1 <br />WATER TABLE DEPTH: O ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />J PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <%4 � C <br />INSTALLATION WILL SERVE: RESIDENCE Ll COMMERCIAL <br />/� I I OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 'v NUMBER OF EMPLOYEES: <br />7 <br />SEPTIC TANK TYPE/MFG /5w / D CAPACITY /-24040 gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES <br />LEACHING CHAMBERS <br />Received <br />B <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />Permit/ <br />Service Re uest # <br />FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />�1(j09 <br />MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />SUMPS <br />WIDTH <br />ft <br />LENGTH <br />DISTANCE To NEAREST <br />WELL <br />DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />SEEPAGE PITS <br />NUMBER <br />WIDTH_ <br />DISTANCE To NEAREST <br />WELL <br /># OF LINES <br />ft <br />FOUNDATION <br />Received <br />B <br />ft <br />ft <br />FOUNDATION <br />Permit/ <br />Service Re uest # <br />ft <br />ft <br />FOUNDATION <br />ft <br />ft <br />FOUNDATION <br />�1(j09 <br />ft <br />ft <br />FOUNDATION <br />ft FOUNDATION <br />LENGTH OF LINES _ <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <br />DEPTH <br />ft PROPERTY LINE <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 COMPENS ION LAWS. <br />MINIMUM H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE A/zAAIL e r DATE <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to D pt <br />COMMENTS <br />of 3 Ft: <br />l <br />Date <br />NLY <br />Area Employee ID# <br />❑ SPE IAL PERMIT - Approved by <br />p Soil Character: <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Rem'tted <br />Date <br />Permit/ <br />Service Re uest # <br />Invoice # <br />Permit ID# <br />�1(j09 <br />svoo un <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />