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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> 3AN 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 EXPIRES 1 YEAR FROM DATE ISSUED <br /> J,f)BADDRESS ` �.i+ 'h�^ k,0 CITY/ZIP <br /> CROSS STREET ��'�- �'�� li�� APN Z-V J D PARCEL SIZE <br /> v <br /> OWNER NAME Grit/)` �'"J L �` PHONE <br /> OWNER ADDRESS / CITY/STATE/ZIP <br /> CONTRACTOR Mj4=',� ^ 4��iv��11"C— S-l': PHONE �r V J DCr a <br /> CONTRACTOR ADDRESS J� CITY/STATE/ZIP �� ) �-� r� -✓a�GJ <br /> r <br /> LICENSE I I C-42 I I C-36 OTHER NUMBER ,,-) --,5:574 EXPIRATION DATE. <br /> l f <br /> WATER TABLE DEPTH: o ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> IV <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIG <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: Ly'<ESIDENCE ❑ COMMERCIAL 11 OTHER _ <br /> NUMBER OF LIVING UNITS: , NUMBER OF BEDROOMS: _ +3_ _ NUMBER OF EM EES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #of C T S!CCpT�'V <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARNTAv �Y <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE FNT ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> _.._._._..11.11. ._.-........ -.._.._.._.- ___ __-- — --- --._—_.--- —_—_ _..__ <br /> LEACH LINES LEACHING CHAMBERS #OF LINES 1 LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL-� ft FOUNDATION��ft PROPERTY LINES r 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 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 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 /> Lel SEEPAGE PITS NUMBERWIDTH rf <br /> * ..��� ft DEPTH �� ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 1101 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 COMPENSATION LAWS. <br /> MINIMUM 24 11ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE "� T� CL�S DATE <br /> � a <br /> DEPARTMENT SE NLY q <br /> Application Acceptedzwk';L'P-z <br /> Date Area V Employee ID# <br /> -4 <br /> Final Inspection By ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS LZJA/ <br /> PE SC Received ec Amount Permit/ <br /> Code INFO B s mitted Date Service Re uest# Invoice# Permit ID# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />