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t(_(('; 3 - <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />CN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />ON -REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS ICt GEl As -r. ►cif CITY/ZIP 1 -j -4 -P -4x t C 1 �i 1)-3 (O <br />CROSS STREET� Ili AP)N 0 % —1O0 q PARCEL <br />(�CA�SIZE 2 <br />OWNER NAME YQrN;F-5 /C' V\ V*' ry1►o; )\ L <br />I C PHONE <br />OWNER ADDRESS I �J - I V - �G/ I% r% . h A CITY/STATE/ZIP S 4oc K 4c, ti <br />CONTRACTOR ` t �(1-� PHONE 7-O- <br />�� V r 3 Z 1 <br />CONTRACTOR ADDRESS 170 , o -y 12 CITY/STATE/ZIP Ld-4,A nem 11 <br />J C 05 I/'� <br />LICENSE I I C-42 )Cq C-36 OTHER NUMBER lira SLAij EXPIRATION DATE �+ 7-0 . �"je <br />PE <br />Code <br />U <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Ll PERC TEST # <br />BUILDING PERMIT # Q AND USE APPLICATI N# <br />TYPE OF WORK: <br />R NEW INSTALLATION REPAIR/ADDITION ENGINEER I�plgil_VE <br />Permit ID# <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRfJ Sgff ONME I�� �r YY <br />INSTALLATION WILL <br />SERVE: j�ESIDENCE 11 COMMERCIAL IJ OTHER NT <br />NUMBER OF LIVING UNITS: �CQ�J( NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />Vf- SEPTIC TANK <br />' + <br />TYPE/MFG I Z«j f n i L - CAPACITY C) gal # OF COMPARTMENTS 2- <br />❑ GREASE TRAP <br />TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION <br />__ __._....._.__.__.....-_. <br />SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />___.. _ _.___ ._ <br />LEACH LINES <br />_._...__.._......_........ ._.. <br />LEACHING CHAMBERS # OF LINES LENGTH OF LINES _ _ ft <br />DISTANCE TO NEAREST W ft FOUNDATION ft PROPERTY LINE U ft <br />❑ FILTER BED <br />WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL _ ft FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLINE ft <br />,U SEEPAGE PITS <br />NUMBER WIDTH ft DEPTH Z S ft <br />DISTANCE TO NEAREST WELL­jj!�Q ft FOUNDATION ft PROPERTY LINE 3 ji // 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 <br />WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPEN$ATION <br />LAWS. <br />MINIMUM <br />HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED� <br />TITLE -J�1�Z'n DATE <br />i <br />to <br />DE ARTMENT USE ONLY '' ) <br />/-1 <br />Application Accepted <br />Date 1 Area "! Employee ID# W <br />Final Inspection By <br />Date ❑ SPECIAL PERMIT - Approved by <br />Character of Soil to Depth <br />of 3 Ft: Pi Sump Soil Character: <br />COMMENTS <br />c - <br />j _ <br />I <' W.,6 J'rift <br />�-IN. z.614 �l �(l!?� �Lu <br />PE <br />Code <br />C <br />INFO <br />Received <br />B <br />Cchec <br />ash <br />Amount <br />Remitted <br />Date <br />PermiU <br />Service Request # <br />Invoice # <br />Permit ID# <br />SSI <br />J 23 i <br />Q��> Ic 2- <br />42-01 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />