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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NONREFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> CROSS STREET ��1 J APIN <br /> c - �¢�/►1--—� PARCEL SIZE - � <br /> OWNER NAME J PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE I I-C-42 ❑ C-36 OTHER NUMBER EXPIRATION DATE <br /> , nl If <br /> WATER TABLE DEPTH:Z ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # 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: RESIDENCE L COMMERCIAL _. OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS:_ q NUMBER OF EMPLOYEES: /f <br /> SEPTIC TANK TYPE/MFG v CAPACITY V gal #OF COMPARTMENTS 21 <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> G <br /> DISTANCE TO NEAREST: WELL FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> .. .. __ IF— <br /> � - <br /> LEACH LINES LEACHING CHAMBERS #OF LINES� LENGTH OF LINES 0 ft <br /> DISTANCE TO NEAREST WELL ' /lft F OI JNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH _ ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> ' DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ` ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOJNDATION 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, 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 COMPENSA111ON LAWS. <br /> MINIMUM OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE <br /> Fmr <br /> JOACIU11 COLI <br /> L <br /> .. EPARTME T SE (INLIW <br /> Application Accepted By 1C Date Area Employee ID# <br /> Final Inspection By Date 0 ❑ SPE IAL P RMIT-Approved by <br /> Character of Soil to Dept of 3 F . Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> o1S42 -7 L46 1016- <br /> 42-01 <br /> -01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />