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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-REFUNDABLE PERMIT CALL 209 953-7697 F R INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1 r __�_ -CITY/ZIP _ __ v <br /> CROSS STREET �"✓ 1 '�'" b S APN_01_5-0 '(o-7CO <br /> PARCEL SIZE * 519 <br /> p <br /> OWNER NAM -/ MSTOV 1 ey " I 0 V V *&n+j ✓�1�//Q l�{ PHONE2Q0�q+4/-- <br /> OWNER ADDRESS 1✓______CITY/STATE21P hwx; U� V5 Lx.J9 <br /> CONTRACTOR t�J© /X� _ PHONE 9607 <br /> 4000 <br /> . <br /> CONTRACTOR ADDRESS t�� ' W l l50� W/tj__CITY/STATE/ZIP S\_nCyzb- ' 525 <br /> LICENSE X C-42 I I C-36 OTHER A NUMBER W5 EXPIRATION DATE u 9 <br /> WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATIO : Coordinates X Y <br /> L PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE I 1 COMMERCIAL Ll OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG L CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG M CAPACITY gal #OF COMPARTMENTS <br /> C V <br /> DISTANCE TO NEAREST: WELL 7 + it FOUNDATION it PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ... . .-_ --- __-........... .......... -- --__.... _ '36 <br /> _._--------- <br /> ❑ LEACH LINES )C LEACHING CHAMBERS GQ '36 #OF LINES LENGTH OF LINES it <br /> DISTANCE TO NEAREST <br /> �/� WELL cJ _+- ft FOUNDATION �7 w ft PROPERTY LINE ft <br /> FILTER BED WIDTH 24 4 <br /> ft LENGTH J1 it DEPTH +' it <br /> DISTANCE TO NEAREST WELL 50+ it FOUNDATION I D it PROPERTY LINE it <br /> ❑ MOUNDED WIDTH it LENGTH it DEPTH it <br /> DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE it <br /> ❑ SUMPS WIDTH it LENGTH it DEPTH it <br /> DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE it <br /> ❑ DISPOSAL PONDS WIDTH it LENGTH it DEPTH it <br /> DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE it <br /> ❑ SEEPAGE PITS NUMBER WIDTH it DEPTH EA it <br /> DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINEUrT n it <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN A&AWITAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY 611 �� S <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN EIY► I ALL <br /> WORKERS COMPENS ION LAWS. TMENT <br /> (MbWAWIM 1AHO YON VA wa OJORCE REQUIRED FOR I CTION -PLEASE CALL 209 9 7 <br /> -7 <br /> SIGNED TITI. DATE I01151201 <br /> EPARTMENTU.SEOAVLY <br /> Application Accepted By Date / Area Employee ID# <br /> Final Inspection By Date 11 SPECIAL PERMIT <br /> IT-Approved by <br /> Character of Soil to De of Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received e # Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted. Service Request# <br /> L �?� Ltd `� I 11ZS <br /> 42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />