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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUINSOUNTY 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 q3 o',S A CITY/ZIP <br /> CROSS STREET 1=�/�/� / APN b 17710 — d A PARCEL SIZE 0• � p <br /> C <br /> OWNER NAME PHONE v <br /> OWNER ADDRESS _ CITY/STATE/ZIP <br /> [`-/ <br /> CONTRACTOR _1�' I f y a,G 5o f' PHONE <br /> CONTRACTOR ADDRESS (10 CITY/STATE/ZIP <br /> LICENSE 1 1 C-42 I I C-36 OTHER NUMBER 606555 -/ EXPIRATION DATE I /� <br /> WATER TABLE DEPTH:�� ' I O ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> D 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 DESTRUCTION <br /> INSTALLATION WILL SERVE: b--ifESIDENCE ❑ COMMERCIAL L OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: J NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG L 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 /> ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES It <br /> � DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> R FILTER BED WIDTH 7-S ft LENGTH I , ft DEPTHy // ft <br /> DISTANCE TO NEAREST WELL , <br /> ft FOUNDATION I�f ft PROPERTY LINES 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 It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERRA 71 ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH RptIme. _ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ® ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH All)V ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft RROPER Y LINE Me ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DON!"t TWITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT M Z.ICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIA WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 OU .ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE �.4�I�f'G�'}�ji" DATE <br /> 25 <br /> AJI <br /> r <br /> FJ <br /> n <br /> � C t <br /> e DEPARTMENT jU S El 0,N L Y <br /> Application Accepted By . Date Area Employee ID#� <br /> Final Inspection By I� I w Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit um Soil Character: <br /> COMMENTS I'-T AffAW M L f�_>AA11 T T3 "1 SZ" IAkLCA <br /> PE SC Received Chec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO ash Remitted 1 /Service R/eques't^# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />