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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SARJOAQUIN 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 YEAR FROM DATE ISSUED <br /> fu 9 JOB ADDRESS U JfEI CITY/ZIPJ\� N <br /> — %� 7 - <br /> CROSS STREET JO O Pl / APN L �O7v 0 , PARCEL SIZE <br /> 0 <br /> t�C z <br /> OWNER NAME Ql iaU NCt� _ r4N CJF�/ r`�n{ PHONE v� <br /> OWNER ADDRESS n V 1 1 Njk&jTY/STATE/ZIP / f III j: <br /> CONTRACTOR -3 q N v(kL(k` Q /i c, PHONE <br /> CONTRACTOR ADDRESS l"�r CITY/STATE/ZIP f(lrI orc l j J`Ii <br /> LICENSE 1 C-42 C-36 OTHER Il NUMBER 7-3/ I 1 EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> Li 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 COMMERCIAL Ll OTHER <br /> NUMBER OF LIVING UNITS: _INUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPE/MFG Il7LlMG 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 /> 1�Q LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES d ft <br /> J` DISTANCE TO NEAREST WELL—[?!t) ft FOUNDATION�A�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 p� ft <br /> C3M SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN Ai, ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH L'®1��+_ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 1A At ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH a ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LI '/OA ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCO � SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED L R$f IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENcS ON LAWS. <br /> MINIMUM 1i HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED \\ TITLE 6gMr DATE4- ' _1 I <br /> EPARTMENT061SK ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Final Inspection Bye" NSG Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTST�( � �. <br /> PE SC Received Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO BV Cas Remitted Service Request# <br /> Z 3 f,) <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />