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• ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> �AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE P RMIT Q4 LL 209 953-7697 FOR INSPECTIO ExPIREV YEAR FROM DAjgjSsVED <br /> JOB ADDRESS , �j�) jam/ CITY/ZI vv <br /> CROSS STREET @ \.k W VI-AL- APN (l� ARCEL SIZE 1 � O A <br /> OWNER NAMEBILL -DsL&jo�o1 V CA rn <br /> PUE <br /> OWNER ADDRESS �_ U [�cA G"ITY/STATE21P <br /> N r <br /> CONTRACTOR •A , ✓ WL PHONE 4766-9 6OT7 <br /> CONTRACTOR ADDRESS4wo wd3a —CITY/STATE/ZIPr5W 5 <br /> LICENSE V C-42 I I C-36 OTHER A NUMBER too 5 LEXPIRATIONDATE 1Lj,j,j <br /> WATER TABLE DEPTH: / Q ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> U 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 DESTRUCTIONMOW <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> �! NUMBER OF LIVING UNITS: �'1 NUMBER OF BEDROOMS: t NUMBER OF EMPLOYEES: <br /> Jp SEPTIC TANK TYPE/MFG V J L CAPACITY 1 gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL 100 1 ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES x LEACHING CHAMBERS 1 94 #OF LINES I LENGTH OF LINES 42 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 ft <br /> J� SUMPS WIDTH L—Aft LENy�H 2O ft DEPTH ft <br /> DISTANCE TO NEAREST WELL CJ ft FOUNDATION S ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ftA. ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LI ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH qk <br /> Cpft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY wcuft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE INW <br /> AN E SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT RAP, I+C�AE�NS,�E IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM ^'y'l ALL <br /> WORKERS COMPENSATION LAWS. E !lik NT <br /> h*M% NjQT10E REQUIRED FOR E TIO S-PLEASE CALL 209 9 3- 97 <br /> SIGNED TITILILAULMOLU DATE 11 <br /> 7411 <br /> kt <br /> 4 <br /> r I _ <br /> 14 <br /> t� � 3{p.y•. <br /> PARTMENT VSE.ONX Y <br /> Application Accepted By Date Area ly Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS &Zrj96=it 70 <br /> �— t7 <br /> PE SC Received h Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO ash Remitted Servi a Re uest# <br /> 2 S 1 l &K CV-711 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br /> A <br />