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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT i Lr? <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDA IT ALL 209 953-7697 FOR INSPECTIONS EXPIRES YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP <br /> CROSS STREET Aq, APN Q� -02n1�� PARCEL SIZE L � 0 <br /> v <br /> tv <br /> L<jjSnk)A_ , <br /> OWNER NAMEM6t_e <br /> C <br /> L JFJ PHONE V VI-5 U <br /> OWNER ADDRESS 1,175 \hj \hjAct_KjLrF 4mgk;3L_CITY/STATE/ZIP LLn I R-514`J <br /> CONTRACTOR ILL DMJ2�514 ( LKIC, PHONE 41`51&9 77 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE Y C-42 I I C-36 OTHER A NUMBER_loo_ _W EXPIRATION DATE <br /> I- <br /> WATER TABLE DEPTH:60 ITO ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATIOP)"RAPAIT <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEEp//y oNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRU CI C��������JJ <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHERS-L-f42f11. 18 <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS:_.. NUMBER OF EMPLOYEES: <br /> SAN JOAQUIN COUNTY <br /> ❑ SEPTIC TANK TYPE/MFG [5"Y1 ILJ U CAPACITY .? gal #OF tNM®TWF_VrAL <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #tkAg0AqfR6REMENT <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_F,�9 44 #OF LINES] LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL_J0nft FOUNDATION 3O 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 /> t' <br /> YI SUMPS WIDTH ft LEN H ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION _ 3 0 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 COMPEN4gION LAWS. <br /> 61&WWf7MH0VR,aVAWZNQTIqg REQUIRED FOR I C IONS-PLEASE CALL 209 53-7 7 <br /> SIGNED LSL/ TITLE AAJJLJ�WDATE <br /> D PARTMENT U E OCZ" <br /> Application Accepted By Date Area Employee ID#� <br /> Final Inspection By ate42Y ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to De h of 3 t: pjVSWp Soil Character: <br /> COMMENTSz� ., i.✓ l v wt/ <br /> PE Sc Received Check#/ Amount Permit/ <br /> Code INFO B Cash Remitted Date Service Request# Invoice# Permit ID# <br /> uL­ ( _-�3 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />