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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P / ' <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697FOFt INSPECTIONSPl ES 1/YEAR FROM DATE ISSUED <br /> ,JOB ADDRESS C�7 CIT <br /> ' R _ Y/ZIP "f{l' X�7AC ✓YS�� - <br /> APN . t Gi PARCEL SIZE L'�' _� p <br /> CROSS STREET <br /> �( L` I I.M J� O <br /> OWNER NAME��ik /p A "j LvM �r- `� PHONE <br /> OWNER ADDRESS 1 y4 • `� CITY/STATE/ZIP �� r <br /> CONTRACTOR S rI G Ag e4<4 2icze r PHONE S is" ,�K�✓Jf �j <br /> CONTRACTOR ADDRESS 0&Ox CITY/STATE/ZIP �I L'� � ` 3 <br /> LICENSE I I C-42 I C-36 OTHER NUMBER(j? EXPIRATION DATE <br /> WATER TABLE DEPTH: I O� Z ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> D PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT LI OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: ��SIDENCE ❑ COMMERCIAL LJ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE I 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 /> a' FILTER BED WIDTH •7 ft LENGTH 114 r ft DEPTH/ D prf ft <br /> DISTANCE TO NEAREST WELL Iaftl ft FOUNDATION IOt ft PROPERTY LINE Id 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 ft 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 FOUNDATION 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 COMPENSATION LAWS. <br /> MINIMUM24HOUR ADVANXE NO ICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 3-7697 <br /> SIGNED TITLE ���1`�s�fC1`r' DATE ' t' <br /> D <br /> y <br /> V) X1 LQL <br /> N 0 J NTY <br /> EIM 1014MI"NIALENT <br /> 7777 <br /> D PARTMENSE LY <br /> Application Accepted By Datef4Z f7 -_lq Employee ID#� <br /> Final Inspection By Date D SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Chec Amount DPermiPermit/Code INFO B ash milted Date Service Request# Invoice# Permit ID# <br /> ti so9kA13093� k s oa 9s <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />