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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT I,J <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE F'ERMII <br />GALL (ZU9) 953-/697 FOR INSPECTIONS tXPIRES 1 YEAR FROM UATE ISSUE <br />JOB ADDRESS I I x `" -t S. C% ✓I to 'i t(, CI 44 Q r4t!jNZ CGP CITY/ZIP IKLILA � A GG C V S �,f /�__ <br />CROSS STREET FY C G wq (/ V ji.L n �}✓A-�PN \ �( PARCEL SIZE <br />OWNER NAME k a ylGY � I[x 2 -jna 1 _ _ PHONE <br />OWNER ADDRESS I k -49-10 5- li✓� L �% �I Ll� —CITY/STATE/ZIP 44,24 Tom: tw Cq <br />CONTRACTOR QC 1J ALLY _ PHONE -1-9O"f .90 2' 110 T - <br />CONTRACTOR ADDRESS <br />LICENSE I I, C-42 ❑I C-36 OTHER <br />CITY/STATE/ZIP <br />NUMBER EXPIRATION <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: 11 NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br />1 REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION t <br />INSTALLATION WILL SERVE: ❑ RESIDENCE 11 COMMERCIAL LI OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY <br />CAPACITY <br />DISTANCE TO NEAREST: WELL ft FOUNDATION <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT <br />❑ LEACH LINES <br />-] LEACHING CHAMBERS <br />Received <br />By <br />Check#/ <br />Cash <br /># OF LINES <br />Date <br />DISTANCE TO NEAREST <br />WELL <br />Permit ID# <br />ft <br />FOUNDATION <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />;;IL <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />❑ MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />❑ SUMPS <br />WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />❑ DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />ft <br />ft <br />ft <br />ft <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 COMPENSATION LAWS. <br />h NIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNE -JCLV lG,rT 1lJL 2xt ('C.y ADATE 12�•P�- <br />AA <br />r DEPARTMENT US ONLY <br />Application Accepted By Date 3 1 2 Area t>j I 06'0I,Employee ID#A\& w� <br />Final Inspection By Date L / ❑ SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of t: Pit/Sum Soil Character: <br />CO NTS I 1- r` � r —i/V Q, Iovl <br />1p <br />(! A k l ov t l ,o .,1, _.l-� .. Y -F�n in F1�0 D.� a ..1 .J�,... � -r-:'t, i A, . M 14 A Ir. L , <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />De 1�) <br />;;IL <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />