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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P✓f* <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON -REFUND =-IRMIT <br />JOB ADDRESS <br />CROSS STREE <br />OWNER NAME &F4 <br />` r r <br />OWNER ADDRESS ` l <br />CONTRACTOR D, A ' <br />CALL (209)953-7697 FOR INSPECTIONS <br />r <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />CONTRACTOR ADDRESS "T -V I V • \fiPITY/STATE/ZIP (]L <br />LICENSE Ix'C-42 1-1 C-36 OTHER NUMBEA On H EXPIRATION DATE V`-' <br />PARCEL SIZE I ` <br />IT <br />t"1{}J.16 I n --.- <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 />WORKE <br />SIGNED <br />DEPARTAfEA Y ��r. <br />Application Accepted By Date Area / _!- Employee !D# <br />Final Inspection By r Date ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth Ft: Pit/Sump.Soil Character: <br />COMMENTS <br />PE <br />Code <br />SC <br />INFO <br />WATER <br />TABLE DEPTH: _3 ft GEOGRAPHICAL INFORMATION: <br />Coordinates <br />X <br />Y <br />❑ <br />PERC TEST #� BUILDING PERMIT # <br />— 1704354 <br />LAND USE APPLICATION # <br />- <br />TYPE OF WORK: NEW INSTALLATION -�-] <br />REPAIR/ADDITION <br />5 <br />❑ ENGINEER DESIGNED/ALTERNATIVE <br /><< <br />REPLACEMENT J <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />I_ DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE <br />❑ COMMERCIAL <br />❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />SEPTIC TANK TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />, <br />f <br />� } <br />DISTANCE TO NEAREST: WELL Cab <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />LIFT STATION SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES LEACHING CHAMBERS /ff <br /># OF LINES <br />1 <br />LENGTH OF LINES 100 ft <br />DISTANCE TO NEAREST WELL10nf <br />ft FOUNDATION <br />_ft PROPERTY LINE ft <br />❑ <br />FILTER BED WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />MOUNDED WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />�j��■1� ft <br />❑ <br />SUMPS WIDTH ft LENGTH <br />ft <br />DEPTH /'�� •"— ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE] rCj "'Lj ft <br />❑ <br />DISPOSAL PONDS WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH Al IlwAft, <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINKCNM�N'�A� <br />wR <br />t"1{}J.16 I n --.- <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 />WORKE <br />SIGNED <br />DEPARTAfEA Y ��r. <br />Application Accepted By Date Area / _!- Employee !D# <br />Final Inspection By r Date ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth Ft: Pit/Sump.Soil Character: <br />COMMENTS <br />PE <br />Code <br />SC <br />INFO <br />ReceivedCheck#/ <br />Bv <br />as <br />Amount <br />Remitted <br />Dae <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />i I <br />S9 83 <br />5 <br /><< <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />