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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 /> NON-REFUNDABLEP�ERMIT c CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS,�3 /p�' �71 /+� �� (/G CITY/ZIP <br /> CROSS STREET / Y�/� /W d APN �(�1 V O 0 PARCEL SIZEC I y <br /> /� 1 /tea_ bf — ��2/ 7RIV> PHONE �J O <br /> OWNER NAME , 12 / C• /I�� o <br /> z <br /> OWNER ADDRESS "'7 /ij , _ CITY/STATE/ZIP <br /> CONTRACTOR � 7 �` �•"r/ PHONE <br /> CONTRACTOR ADDRESS / CITY/STATE/ZIP52 <br /> 9.52 <br /> LICENSE I Ii C-42 DF-C-36 OTHER NUMBER -" �J <br /> EXPIRATION DATE / /2-io <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> l PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIWADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM xDESTRUCTION <br /> INSTALLATION WILL SERVE: Ll RESIDENCECOMMERCIAL LL OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> eC 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 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 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 IVe.I, ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH 1D ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY Lt OA0 1 �'q ft <br /> L3SEEPAGE PITS NUMBER WIDTH ft DEPTH HEA[] R�,�NM(� NTY ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 'U�hART"M�E�, 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 COMPENS ION LAWS. <br /> MINIMUM VA NOTICE REQUIRED FOR INSPECTIQNS <br /> A -PLEASE CALL 209 9 <br /> SIGNED TITLE DATE <br /> fA <br /> 4 <br /> DEPARTMENT USE ONLY / <br /> Application Accepted By Date -� Area �1/fray Employee ID# Ahe <br /> Final Inspection By ZTN Date �/� ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Caracter: <br /> COMMENTS yj;i be l0 "-Ir 6T <br /> PE SC Received Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By,,n Cas Remitted Service Request# <br /> 12I S Aa <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />