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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 />NON-REFUNDABLE PERMIT GALL (209) 953-7697 FOR INSPECTIONS <br />,+ EXPIRES 1 YEAR FROM DATE ISSUE <br />I <br />JOB ADDRESS 2��JJ2,�.Z��,/��,���5 N. , Jd�(/V�D/V zo CITY21P [_LE/✓.�'/VT_S yS.3-3O <br />CROSS STREET n/-rC�IY +r -a APN._�3_O D O PARCEL SIZE <br />OWNER NAME K ,4AaP t 6EGKy 9.4T/jM PHONE Z�9- y9S -Z87� <br />OWNER ADDRESSSw CITY/STATE/ZIP <br />CONTRACTOR //A�-� GO'uysp%2L✓� !AWA/ I&r_' PHONE a - oy' Alk <br />Zo <br />CONTRACTOR ADDRESS �.//L�/ e�� �. —CITY/STATE/ZIP 940 1_(A.J W Chi <br />LICENSE ❑1 C-42 ❑OC -36 OTHER /d Y NUMBER t Q T -I> t7 aPIRATIONDATE_N `i <br />WATER TABLE DEPTH: I (jj L it GEOGRAPHICAL INFORMATION: <br />❑ PERC TEST # BUILDING PERMIT # <br />TYPE OF WORK: NEW INSTALLATION '-4 REPAI DE <br />Coordinates X Y <br />LAND USE APPLICATION # <br />)N ENGINEER DESIGNED <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM i ! DESTRUCTION <br />INSTALLATION WILL SERVE:/RESIDENCE LI COMMERCIAL ❑ 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 _ it FOUNDATION <br />❑ LIFT STATION SIZE TYPE OF PUMP_ ❑ PKG TX PLANT <br />TERNATIVE <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE it <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES ❑ LEACHING CHAMBERS _ # OF LINES _� <br />LENGTH OF LINES J ( <br />it <br />DISTANCE TO NEAREST <br />WELL it FOUNDATION Z5 / <br />it PROPERTY LINE <br />it <br />❑ FILTER BED WIDTH <br />ft LENGTH ft <br />DEPTH <br />it <br />DISTANCE TO NEAREST <br />WELL it FOUNDATION <br />ft PROPERTY LINE <br />it <br />❑ MOUNDED WIDTH <br />it LENGTH it <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL it FOUNDATION --- <br />it PROPERTY LINE <br />it <br />SUMPS WIDTH VI <br />ft LENGTH )Z I _ it <br />DEPTH SI <br />it <br />DISTANCE To NEAREST <br />WELL - it FOUNDATION <br />it PROPERTY LINE <br />it <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH _ ft <br />DEPTH <br />it <br />DISTANCE TO NEAREST <br />WELL 1t FOUNDATION _ <br />ft PROPERTY LINE _ <br />it <br />EEP ITS NUMBER <br />WIDTH _ft <br />DEPTH <br />it <br />DISTANCE TO NEAREST <br />WELL,_ ft FOUNDATION �_ - <br />ft PROPERTY LINE _ � _- <br />it <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL <br />BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, <br />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 />SIGNED <br />Uri IIy0r1= i i wwa - ri_cnoc lin LL rcu�� ✓--.�//-i v�`i <br />TITLE !%r/Iyl%Z DATE <br />CDEPARTMENJ U E ONLY <br />Application Accented <br />/B,yAd,J, Date kilki Is Area Employee ID# <br />Final Inspection ByDate__ < ❑ SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: _ _ Pit/Sump Soil Character: <br />CON,IIVIENTS car . .� <br />o�t� <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted - <br />Date <br />PermiU <br />Service Request # <br />Invoice # <br />Permit ID# <br />�z ►:. <br />5 v <br />2�3 <br />1 IRo <br />C)IIs <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />