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ONSITE WASTEWATER TRE�ITMENT SYSTEM PERMIT <br /> r SCAN 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 /> JOB ADDRESS az4lCITY/ZIP til (�T <br /> :.I <br /> CROSS STREET k I-C, APN !/ PARCEL SIZE p <br /> d <br /> OWNER NAME ,W1- 41 Cts PHON J ZD7&2-/(q02 <br /> OWNER ADDRES-S�j CITY/STATE/ZIP <br /> CONTRACTOR b 2iAr- awwer( 0-aw P'0'r-: I PHONED!q (eOLf - IV(/ <br /> CONTRACTOR ADDRESS �p a G o SO,4 re - /7L CITY/STATE/ZIP <br /> LICENSE I II iC-42 I 11 C-36 OTHER G -Zy NUMBER V Lld 7t EXPIRATION DATE <br /> WATER TABLE DEPTH: Ii/� ' ft GEOGRAPHICAL INFORMATI C ordl tes X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION i R PAIR/ADDITION i ENGINEER DESIGNED/ALTERNATIVE <br /> 11 REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE 1-1 COMMERCIAL �/ U OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: .- NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS v <br /> GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> 1 <br /> DISTANCE TO NEAREST: WELL ( (�0 fi ft FOUNDATION �2 I ft PROPERTY LINE t D I f- It <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> f LEACH LINES I I LEACHING CHAMBERS {. #OF LINES -zl- LENGTH OF LINES 0 ft <br /> l` DISTANCE TO NEAREST WELL I oo It FOUNDATION t _f ft PROPERTY LINE 13 It <br /> ❑ FILTER BED WIDTH It LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH YAA �( <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE p']�It <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE MAR n 7 ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH S ' ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LI �ENi/lo-P,._ CC)".-ftAI A, <br /> ICS Ep� 1,T- <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE Offtiw <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 L <br /> MINIMU HOUAWSANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 q <br /> SIGNED TITLE k/Nf�DATE 3— 77 / <br /> E P A R T M E N T AJ S Q ONLY /� <br /> Application AccepteADeh <br /> Date I Area `'r Employee ID#A6-�/ <br /> Final Inspection By Date L 1 SPECIAL PERMIT-Approved by <br /> Character of Soil to of 3 Ft: Pit/ ump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remitted Service Request# <br /> 1 i i 5�c_ 3 1°1 S2o 03� <br /> 42-01 U ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />