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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT i'v' <br />CA R1 III A/I111A1 Pni IK -V AIAI C AIT A I W- AI TIS n—A—RA—M 1 ACA G W A— TlI I.I A\/CAMC _ CTl1/`IlTIIAI r^A QS7(19Z _ 1'3nQ% ArSG_11 Anr% <br />NON-REFUNDABLE PER CALL 2 9 9 <br />Cl <br />JOB ADDRESS 1 <br />CROSS STREET /Jt c / I1CV APN <br />OWNER NAME <br />� � <br />OWNER ADDRESS Q V I C� rye r✓I( <br />CONTRACTOR f 2' �1v! � <br />FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI <br />CITY/ZIP C 5d V ). <br />AAt -U \ 0 <br />CONTRACTOR ADDRESS ' 4� , <br />d Am LICENSE I I C-42 11 C-36 OTHER NUMBERggO5J <br />PARCEL SIZE % <br />,^ <br />PHONE 33 �- �jly� �J <br />Y/STATE/ZIP I '�� C//` <br />PHONE U I 33 ^ 13 <br />CITY/STATE/ZIP <br />EXPIRATION DATE <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />\� <br />1. PERC TEST # <br />ft PROPERTY LINE <br />tt <br />BUILDING PERMIT # <br />LAND USE APPLICATION # <br />ft <br />TYPE OF WORK: <br />NEW INSTALLATION <br />REPAIR/ADDITION <br />ENGINEER DESIGNED /ALTERNATIVE <br />ft DEPTH <br />REPLACEMENT <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE <br />❑ COMMERCIAL <br />L! OTHER <br />ft <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />ft <br />SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />ft <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 />❑ LEACH LINES LEACHING CHAMBERS # OF LINES <br />LENGTH OF LINES <br />It <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />tt <br />❑ FILTER BED WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ MOUNDED WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SUMPS WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />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 />WORKERS COMPENSP ION LAWS. <br />MINIMUM HOUR ADVANCE NOTICE REQUIRED F017 INSPECTIONS - PLEASE CALL (209)953-7697 <br />SIGNED r�A06 - ULAq"-'- -1J TITLE 4V11t;2 %I / DATE <br />Application Accepted By- Date <br />Final Inspection By Date <br />Character of Soil to Depth of At: <br />COMMENTS <br />IS F. izuoiY <br />Area Employee ID# <br />i <br />/ / ❑ SP IAL ERMIT - Approved by <br />PiUSump Soil Character: <br />U_ <br />Y <br />T <br />PE <br />SC <br />INFO <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />emitted Date <br />Permit/Code <br />Service Request # <br />Invoice # <br />Permit ID# <br />42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />