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SR0079428
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4200/4300 - Liquid Waste/Water Well Permits
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SR0079428
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Entry Properties
Last modified
10/3/2018 2:12:56 PM
Creation date
9/12/2018 10:36:47 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
SR0079428
PE
4222
STREET_NUMBER
31888
Direction
S
STREET_NAME
DETERMINATION
STREET_TYPE
RD
City
TRACY
Zip
95376
APN
25534006
ENTERED_DATE
7/23/2018 12:00:00 AM
SITE_LOCATION
31888 S DETERMINATION RD
P_LOCATION
99
P_DISTRICT
005
QC Status
Approved
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DAfonskaia
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EHD - Public
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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />GALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS _ <br />�j <br />6 <br />5 . U e 7-er �'r►��n AT: PA I�PyA <br />CITY/ZIPTr G I J ` 3 <br />CROSS STREET <br />_ �J e (�A G1 <br />ylfj &r m(' /\ APN _ <br />r �R v%� PARCEL SIZE <br />OWNER NAME_M <br />�QI TbS <br />❑ SUMPS WIDTH ft LENGTH <br />PHONE <br />OWNER ADDRESS <br />3l GJ �� <br />S `e7-etm;rNq ripA Y�DI.IGQ <br />CITY/STATE/ZIPS3 <br />CONTRACTOR <br />TAG G <br />>F 0e, % <br />7�rpQ�Ql.7 /CfJ <br />PHONE L — <br />CONTRACTOR ADDRESS I (,,7PSt <br />2 S T, <br />CITY/STATE/ZIP Tracy , C'4 9.T 3 (o <br />LICENSE I I C-42 <br />! I C-36 OTHER <br />NUMBER r�f✓ � <br />EXPIRATION DATE <br />ATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />I N -i—=—E <br />PERC TEST # SO t BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: Ll RESIDENCE El COMMERCIAL L. 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 />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES LEACHING CHAMBERS # OF LINES <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ FILTER BED WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />It PROPERTY LINE ft <br />❑ SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE 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, STATLAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE C I RNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPEN ION LA <br />MINIMUM 140U CE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 953-7697 <br />SIGNED TITLE_�V J-C� / Y�PSjili�St� <br />DATE W A3 <br />Application Accepted 6y <br />Final Inspection By <br />Character of Soil to Depih of <br />COMMENTS C% <br />DEPARTMENT USEO Y <br />Date �✓- Area Employee ID# <br />Date '131_ ❑ SPECIAL P RMIT - Approved by <br />Pit/Sump SCSI Character: <br />A 1, " 1 I A _ _ i) I rlt I I_ nL Lnr <br />; S A I- <br />,< KV <br />T <br />PE <br />Code <br />SC <br />INFO <br />ReceivedCheck <br />B <br />ash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />�o� `1 <br />X3-1 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />
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