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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT F ✓` <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT/ n CALL 209 953-7697FoR INSPECTIoNs EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS / /✓ e e CITY/ZIP 'e_n 'l <br /> CROSS STREET J 44a/GA O APNZzl__= _ PARCEL SIZE p <br /> +OWNER NAME 4✓ G <br /> e� .4l L+ 1 r PHONE 2,0 <br /> OWNER ADDRESS f 0 B�! / Z Mall4tI'I`HSTATE21P <br /> CONTRACTOR / ot/(f S M' a,5fe Ile PHONE <br /> CONTRACTOR ADDRESS 0 O 2_/ CITY/STATE/ZIP '/J�JP.-qd 1e' <br /> LICENSE L 'C_42 I_I C-36 OTHER NUMBER Mill EXPIRATION DATE �D <br /> WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION �#A REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT I I OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: it RESIDENCE ❑ COMMERCIAL I 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 ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES�i LENGTH OF LINES ft <br /> t <br /> DISTANCE TO NEAREST WELL f ►3 ft FOUNDATION 1 0 r ft PROPERTY LIN 0 ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH °Q^1— ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROIY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH it DEPTH 16.'104— ft <br /> DISTANCE TO NEAREST WELL _ ft FOUNDATION ft PROP �N �' ft <br /> ❑ SUMPS WIDTH ft LENGTH _ ft DEPTH o�Aft <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINEwV74A( ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH _ _. ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUN/D�ATION ft PROPERTY LINE ft <br /> C'( SEEPAGE PITS NUMBER I WIDTH "7 1 4' __ft'DEPTH ` ft <br /> DISTANCE TO NEAREST WELL )SDS ft FOUNDATION U It PROPERTY LINE '90* ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BL 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-76977 <br /> SIGNED TITLE R",WDATEAwAl ell- <br /> EPA RTMENT LOSE ONJL Y <br /> Application Accepted B Date_ Area wrq— Employee ID# <br /> Final Inspection By Date I I SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: f Pit/Sump Soil Character: <br /> COMMENTS ', . s lr�d o n 9- .2n-ik- <br /> PE SC Received Check Amount Permit! <br /> Code INFO B emitted Date Q Service Request# Invoice# Permit ID# <br /> J �D <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />