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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 />1 <br />INUN-NEFUNDABLE PERMIT <br />TYPE/MFG <br />GALL ZU9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS t�sO <br />CROSS STREET <br />L <br />CITY21 <br />APN A PARCEL SIZE <br />TYPE/MFG ,`b'1\ 45;,2-%a <br />�L <br />OWNER NAME 1 !-sd� <br />A -N <br />r� ` <br />C�`,...-0'1 s 1 <br />PHONE <br />DISTANCE TO NEAREST: WELL _)_ <br />OWNER ADDRESS C, � <br />CONTRACTOR SI <br />r=4t4 <br />L i `��5b <br />y� <br />V U �G.�� n <br />�p�1 <br />\� CITY/STATE21PP�CA/ A yq-)!�.V`�J/��C%� <br />PHONE 4( 1'tflcis <br />SIZE TYPE OF PUMP <br />�O <br />_" <br />r�c� / <br />CONTRACTOR ADDRESS <br />LICENSE I I C-42 L C-36 OTHER <br />CITY/STATE/ZIP <br />NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: <br />1-1 PERC TEST # BUILDING PERMIT # <br />TYPE OF WORK: NEW INSTALLATION R AIR/ADC <br />Coordinates X Y <br />LAND USE APPLICATION # <br />IN ENGINEER DESIGNED <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: LL RESIDENCE ❑ COMMERCIAL L OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />TERNATIVE <br />❑ SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal <br /># OF COMPARTMENTS <br />GREASE TRAP <br />TYPE/MFG ,`b'1\ 45;,2-%a <br />CAPACITY � E) <br />gal <br />p <br /># OF COMPARTMENTS Z- <br />INFO <br />DISTANCE TO NEAREST: WELL _)_ <br />ft FOUNDATION L <br />ft <br />PROPERTY LINE � I ft <br />El STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />ILEACHING CHAMBERS <br />Received <br /># OF LINES <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST <br />WELL <br />INFO <br />ft <br />FOUNDATION <br />Flemitted <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 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 />❑ 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 />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•AIION LAWS. <br />SIGNED <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to Dep of 3 <br />COMMENTS ArVUi% <br />W-���Ed <br />VANC_E_ _NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-769 <br />■■■■■■■■■��■■■■!.�■■■■■■■■■■■�■■■■ .. <br />Date <br />Date <br />t <br />St UN Y <br />Area Employee ID# <br />r <br />❑ SPECIAL PERMIT - Approved by <br />PASO Soil Character: <br />PE <br />SC <br />Received <br />Amount <br />Permit/ <br />Code <br />INFO <br />By, <br />Cash <br />Flemitted <br />Dante <br />Request # <br />Invoice # <br />Permit I 19 <br />tlService <br />0-0 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />