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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN J04OUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 2y09/ 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �c ,r Po 7-+}— wit )CITY/ZIP /�C �L , 4,v4 '15� '331 <br /> CROSS STREETAPN � 3 do 3 b PARCEL SIZE CI o <br /> 0 <br /> OWNER NAME i J 1 b en K r ` PHONE <br /> OWNER ADDRESS 1 I J -� l G V� _ r __ CITY/STATE/ZIP a G/1 4 c Gr <br /> CONTRACTOR L' 1 1 1 `S-L�s�^i PHONE � 7liry��-%)-W'-S' <br /> CONTRACTOR ADDRESS T'CS A, - W 7�✓ CITY/STATE/ZIPY'1 <br /> LICENSE I I C-42 ❑ C-36 OTHER tY NUMBER t'S5 EXPIRATIONDATE E1 <br /> WATER TABLE DEPTH: 2 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> I I PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATIO REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> i✓ REPLACEMENT 111A VI YLL rl OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: , ESIDENCE I I COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: y •I NUMBER OF BEDROOMS: -I ) 1 NUMBER OF EMPLOYEES: <br /> a <br /> SEPTIC TANK TYPE/MFG L. CAPACITY ErX 37 gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ��j ft FOUNDATION: ft PROPERTY LINE 1"j, ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> FILTER BED WIDTH 1 ft LENGTH 'l , ft DEPTH J Y I ft <br /> DISTANCE TO NEAREST WELL� f ft FOUNDATION I.7 f ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE p, ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LI fWSCIV_ ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYLI ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ` NJ��B ft <br /> It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PRO FI$ VIN ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCOR'pp <br /> Q9R3Pl� H SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LI NSE 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 /> MINIMUM 2116UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLEDATE 1 r J <br /> 14-1 1 <br /> - c- <br /> aj- <br /> Z <br /> 1D PARTMENT USE ONLY ,nuA1 <br /> Application Accepted By Date I Area P'UnI Otmployee ID# <br /> Final Inspection By IVc �l� Date 711XI1, ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS Ti ;' r � �.J iA : 1•Ir,;+ <br /> i <br /> Gr1�0s uJ;� ) I t ! !�r ��11u(,he <br /> PE SC Received he Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Remitted Service Request# <br /> I)U ;► o -753 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />