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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 CALL 209 953-7697 FOR INSPECTIONS <br /> ,^ EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS \ YI Ll CITY/ZIP `104 r4C& �.� - y <br /> CROSS STREET �-i 47 APN � �©�' PARCEL SIZE !/ v v <br /> _ �d <br /> OWNER NAME /. • <br /> PHONE ` _T? <br /> OWNER ADDRESS _J]��� ?� Lid CITY/STATE/ZIP �����j ' <br /> D' t �y� i <br /> CONTRACTOR 4! 91�Z� r eL �V�� C�/ �1 54' r. PHONE ' �2�/�y�`�m -s' ` x <br /> CONTRACTOR ADDRESS X10 ch. &SCJ �y� CITY/STATE/ZIP I "no it �+! 4-5 ✓:r& <br /> LICENSE C-42 LJI IC-36 OTHER NUMBER '.._✓ EXPIRATION DATE <br /> I(11 II\\ 1 <br /> WATER TABLE DEPTH: ` '7, ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT LAND USE APPLICATION# <br /> TYPE OF WORK: I I NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: L RESIDENCE COMMOTHER <br /> ERCI <br /> NUMBER OF LIVING UNITS: t 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 /> 9,11LEACH LINES LEACHING CHAMBERS #OF LINES�_ LENGTH OF LINES Vr ft <br /> t' <br /> DISTANCE TO NEAREST WELL ft FOUNDATION IrJ ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH It 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 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE q ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH t.. . ® ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE f• ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH SAN jo, ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPER E IWU/ ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCET1RAN <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 48 HqVR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE �'�+\ I` �cc+fJ _ DATES <br /> rt <br /> -i <br /> EPARTMENT USE y <br /> Application Accepted By Oate Area Employee ID# <br /> Final Inspection By Dat <br /> ef z� LI $PE IAL PERMIT-Approved by <br /> Character of Soil to 164epth of 3 Ft: )Pit/Sump Soil Character: <br /> COMMENTS �� 1AA41 <br /> PE SC Received heck Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B mitted Service Request# <br /> v Z H c�--I c SI d <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />