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ONSITE WASTEWATER `i -IRI E ATMENT SYSTEM PERMIT P✓ <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS ,Kl� (I �1.1�'r OK, 9,D _ __ ___CITY/ZIP 5To 's -Lo <br />cl <br />CROSS STREET JN Y/t V N APN 07-Z �� /3 <br />_ _ } - PARCEL SIZE <br />OWNER NAME IGi/ i 1 - �� L j-� L .�'�` NE O�� <br />OWNER ADDRESS 10ZS _IE:D&NJ Aim__ _- ____ CITY/STATE/ZIP 7 <br />CONTRACTOR VvES7V COA*CT P►►JSC�Cr=.7 I_NfC ' PHONE - ( * -339 -A�� 1 1, <br />CONTRACTOR ADDRESS 33 kA1_7�-�l k_) _ _ __. _t____ ._ _CITY/STATE/ZIP _ Lo D� C' I5 ��y <br />LICENSE ❑. C-42 ❑' C-36 OTHER �2 NUMBER EXPIRATION DATE ZD Z� <br />WATER TABLE DEPTH: <br />_ ft GEOGRAPHICAL INFORMATION: Coordinates X <br />_ Y <br />❑ PERC TEST # <br />BUILDING PERMIT # <br />. __ __ __ . ____ LAND USE APPLICATION # <br />TYPE OF WORK: <br />I NEW INSTALLATION <br />REPAIR/ADDITION <br />ENGINEER DESIGNED /ALTERNATIVE <br />SUMPS <br />1 REPLACEMENT <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />DESTRUCTIONT IAC' <br />X <br />INSTALLATION WILL SERVE: ❑ RESIDENCE <br />I I COMMERCIAL <br />I OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: _ <br />NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG <br />CAWITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG _ _ <br />CAPACITY <br />gal # OF COMPARTMENTS <br />ft PROPERTY L <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />_ ❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />WELL <br />ft <br />FOUNDATION <br />r - <br />❑ LEACH LINES LEACHING CHAMBERS <br />WELL _ It <br />ft LENGTH <br /># OF LINES LENGTH OF LINES ft <br />FOUNDATION It PROPERTY LINE ft <br />ft DEPTH ft <br />WELL <br />DISTANCE To NEAREST <br />FILTER BED <br />WIDTH <br />ft PROPERTY LINE It <br />DISTANCE TO NEAREST <br />MOUNDED <br />WIDTH <br />ft <br />DISTANCE To NEAREST <br />SUMPS <br />WIDTH <br />ft <br />DISTANCE TO NEAREST <br />DISPOSAL PONDS WIDTH <br />ft PROPERTY <br />DISTANCE TO NEAREST <br />SEEPAGE PITS <br />NUMBER _ <br />DISTANCE TO NEAREST <br />WELL _ It <br />ft LENGTH <br /># OF LINES LENGTH OF LINES ft <br />FOUNDATION It PROPERTY LINE ft <br />ft DEPTH ft <br />WELL <br />ft <br />FOUNDAT ION <br />Cas <br />ft PROPERTY LINE It <br />ft LENGTH <br />Invoice # <br />Permit ID# <br />ft <br />DEPTH <br />ft <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY <br />F It <br />ft LENGTH <br />ft <br />DEPTHIns <br />_ 71 ft <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY L <br />! <br />♦i I ft <br />ft LENGTH <br />_ <br />ft <br />DEPTH _ <br />It <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY L <br />E 2Q1g_ ft <br />WIDTH <br />ft DEPTH SAN <br />NNJO ft <br />ft FOUNDATION It PROW fM1l�� MEUZ,�.N�_ 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 COMPENSATION LAWS. <br />MI IMU " 4 UH VHI Ivv l n,c rrct,rurrrcu rvn nv�rcr,. � www - r�cno�. vn�� w� <br />SIGNED ° _ TITLE__ DATE <br />EPARTMENT SF_ N Y <br />Application Accepted By _ Date _ 7 - - t6V--- - — Area Employee I D#� <br />Final Inspection By ___ Date_ -E- Ll SPECIAL PERMIT - Approved by <br />Character of Soil to.Depth of 3 Ft: _ _____ Pit/Sump Soil Character: <br />COMMENTS Cxfr;e <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Cas <br />Amount Date <br />Remitted <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />2 <br />W <br />,! � � <br />q,, <br />..1/ ISrC� <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />