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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT r n , <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 Y R FROM DATE ISSUED <br /> JOB ADDRESS S SDIj CITY/ZIP lozpfl v <br /> CROSS STREET APND PARCEL SIZE <br /> OWNER NAME `C h f I I t PHONE <br /> OWNER ADDRESS rr � CITY/STATE/ZIP <br /> CONTRACTOR //Jl�y I /V�-J(A/11 PHONE (2b y_J,l� _<-Qa/ L <br /> CONTRACTOR ADDRESS �3i e f�lSoH l/i - CITY/STATE/ZIP C/ /Of <br /> LICENSE 111`4'�42 11 C-36 OTHER NUMBER 44�04t�_ EXPIRATION DATEIrk <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> LL PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ENGINEER DESIG ED/ALTERNATIV <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL ERVE: RESIDENCE F] COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG G CAPACITY ��Q6 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 I LEACHING CHAMBERS r #OF LINES LENGTH OF LINES �® ft <br /> a0 ft <br /> DISTANCE TO NEAREST WELL/06 ft FOUNDATION _ft PROPERTY LINE <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 ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft vFOUNDATION ft PROPERTY LINE ft <br /> SEEPAGE PITS NUMBER WIDTH '�P ft DEPTH ft <br /> DISTANCE TO NEAREST WELL /50 ft FOUNDATION /0 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 COMPENS�I�TION LAWS. <br /> MINIMUM 94 HOUR ADVA NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE 1 <br /> O� DATE �� I7-/,4' <br /> Z <br /> w <br /> a <br /> All 111 <br /> w <br /> c7 0 <br /> z <br /> x <br /> T � <br /> D P RTMEN SE &NL V <br /> Application Accepted By Date r7 Area Employee ID# <br /> Final Inspection By `�-G✓t Date 1 ❑ SPECIAL PER -Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS hh/ ,S / I/VG 77AAZK gel CS D 6A4�i'' <br /> PE Sc Received heck#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Cash Remitted Service Request# <br /> o 2-->-7cn ot 4 S <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />