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4 <br /> 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 <br /> /PERMIT CALL 20.2)953-7697 FOR INSPECTIONS XPIRES 'I YEAR FROM DATE ISSUED <br /> JOB ADDRESS ` L� 1 / L� CITY/ZIP ff <br /> CROSS STREET �� APN "2 2 !S 1 9 PARCEL SIZE <br /> J l7 V PHONE <br /> OWNER NAME / <br /> I� y .�G��V�u <br /> OWNER ADDRESS // CITY/STATE/ZIP <br /> 4J 7TI �� PHONE <br /> CONTRACTOR ��//�� " � r� <br /> CONTRACTOR ADDRESS 0 VF' A.L'�` � CITY/STATE/ZIP �f l". • Zci <br /> LICENSE I 11 C-42 I Ii IC-36 OTHER NUMBER �� 3 EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# %L: `C 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: ;K, RESIDENCE 1_1 COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 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 /> T� LEACH LINES i3O' LEACHING CHAMBERS #OF LINES LENGTH OF LINES dR-!' 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 It <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH PA V,%. ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN It <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LI ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH SqN ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPE)4 1 ''W Q� ft <br /> eE�- pI-'IzIV T� <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDInur/ rH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LI SE 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 HWJR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE 7�' �' DATE <br /> a.- <br /> r" . <br /> DEPARTMENT SE ONLY <br /> Application Accepted By ;7'> Area ��t( Employee IDA <br /> Final Inspection By Date I 1 SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received ec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Bash Remitted Service Request# <br /> 42-16' 11 :7 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />