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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 />N:ON-REFUND B MIT a iPALL 209 9-7697'FOR r, INSPECTIONS EXPIRES 1 Y R F DATE ISSUED <br />JOB ADDRESS VwxCITY/ZIP r, <br />b0ROSS STREET <br />OWNER NAME Row, <br />ICk�/ <br />APN 11-7-100-130 <br />"J� <br />PARCEL <br />PHONE <br />OWNER ADDRESS � <br />+� <br />Q� <br />W4"' l V + l 1.J1"'l/\ <br />p� j <br />A 1 V'd CITY/STATE/ZIP <br />CONTRACTOR <br />REPAIR/ADDITION <br />HONE <br />6 n 6 (3� <br />REPLACEMENT <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />- <br />FILTER BED <br />CONTRACTOR ADDRESS <br />1 l V` <br />JCS �� CITY/STATE/ZIP r <br />LICENSE IY9 C-42 I <br />C-36 OTHER A <br />NUMBER O EXPIRATION DATE <br />AIAt <br />WATER TABLE DEPTH: ft <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />LEACHING CHAMBERS <br />- <br />❑ PERC TEST # <br /># OF <br />BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION <br />REPAIR/ADDITION <br />It ff <br />ENGINEER DESIM4ED 1Ak1rE2MNVE <br />REPLACEMENT <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />DESTRUCrAil 11.11 - <br />FILTER BED <br />INSTALLATION WILL SERVE: RESIDENCE <br />❑ COMMERCIAL <br />Ig <br />❑ OTHER yp-4 IRON qS,.O�UNT, <br />NUMBER OF LIVING UNITS: <br />NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYE 'q'IV <br />AIAt <br />SEPTIC TANK TYPE/MFG.i M-15 J0 11 FULA 141 CAPACITY 1 )Jv gal # OF COMPARTMENTS f—� , <br />❑ GREASE TRAP TYPE/MFG �sI CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL tel' 4 DATION 15-+- ft PROPERTY LINE r ft <br />❑ LIFT STATION SIZE TYPE OF PUMP JJ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />94 <br />LEACH LINES <br />LEACHING CHAMBERS <br />Check#/ <br />Amount <br /># OF <br />ft <br />Code <br />DISTANCE TO NEAREST <br />WEL <br />Cash <br />ft <br />f� l <br />FOUNDATION ft ft PROPERTY ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION ft PROPERTY LINE) <br />❑ <br />MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION ft PROPERTY LINE <br />It <br />SUMPS <br />WIDTH <br />t <br />DEPTH <br />DISTANCE TO NEAREST <br />WEL <br />f <br />I <br />ft <br />PROPERTY LINE ==7S <br />❑ <br />DISPOSAL PONDS WIDTH <br />It <br />LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION ft PROPERTY LINE <br />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 />WORKE <br />SIGNED <br />Application Accepted By -L,2 <br />Final Inspection ByG <br />Character of Soil to Depth of <br />COMMENTS O�'CO <br />DEPARTMENT USE O LY <br />Date Z AreaZI`S! f-- Employee ID#b/�() <br />Date / ❑ SPECIAL PERMIT - Approved by <br />Pit/Sump Soil Character: <br />PE <br />SC <br />Received <br />Check#/ <br />Amount <br />Permit/ <br />Code <br />INFO <br />By <br />Cash <br />Remitted <br />Date <br />Service Request # <br />Invoice # <br />Permit ID# <br />1. <br />.d <br />4 5/5/17 2-01 U'- 2P� � U lJ ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />DJ <br />