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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT , <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT �` i CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEEA�R-FROM DATE ISSUED <br /> JOB ADDRESS /05-0ELk /ior'bI ODA. CITY/ZIP sT�G fLa�v /���� <br /> _ m <br /> CROSS STREET P/9u1S ��. J APN -k-- Q 7O PARCEL SIZE q <br /> O <br /> v <br /> tom,, x <br /> OWNER NAME_ ilk_1545W I e x erre y &e oS PHONE s <br /> i — p n <br /> OWNER ADDRESS 1050 LrLX /It /V 1P*1Q_ CITY/STATE/ZIP SJCX-X TUN ��• 9SoZ0 1 <br /> CONTRACTOR WIE5 CDI�S T �j�C/�` CSE .� -I'V 4. PHONE \^ <br /> CONTRACTOR ADDRESS 33 CITY/STATE/ZIP /_C7yZ Lv9• 9SoZ�l d V►� <br /> LICENSE I 1 C-42 I I C-36 OTHER NUMBER &J /1.S7 EXPIRATION DATE 1;2Oo30 <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATI N REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT (i OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESI ENCE COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES:_ <br /> SEPTIC TANK TYPE/MFG L CAPACITY WJJ gal #OF COMPARTMENTS <br /> GREASE TRAP TYPE/MFG -W f� CAPACITY gal #OF COMPARTMENTS Z <br /> DISTANCE TO NEAREST: WELL N ^ 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 bA. ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE1 <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTHA&F It ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE WAZLI <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH 7n.n ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE L'/� oft ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCOR6WQel- A <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED L6 y)6 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENS ON LAWS. <br /> MINIMUM OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE �(��t���� DATE <br /> E� s 1v <br /> Drt ARTMENT USE QfNIAY <br /> Application Accepted ByDate Area �� Employee ID# V , <br /> Final Inspection By If DateLlSPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/�Character: <br /> COMMENTS <br /> PE SC Received Ch Amount Permit/ <br /> Code INFO B s emi ed Date Service Request# Invoice# Permit ID# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />