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I ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JGAOUIN COUNTY ENVIRONMENTJL EALTH DEPARTMENT 1868 E.HAZELTON AVENUE-S-,OCKTON CA 95205-(209)468-3420 <br /> , VON-REFUNDABLE PERMIT Ib7 CALL 209 953-7697 FOR INSPEG-TI JfVS EXPIRES t YEAR FROM DATE ISSUED <br /> JOB ADDRESS M Ile 01 OAF CITY/ZIP <br /> - =3 <br /> ri'v�'�' ar► <br /> CROSS STREET - r APN V�J <br /> - PARCEL SIZE d <br /> OWNER NAME -.. PHONE <br /> OWNER ADDRESS 5 � G� e CITY/STATE/ZIP -7 <br /> CONTRACTOR /5 /��PHONE L (.y® - f? Jf—^0/3 YZ <br /> CONTRACTOR ADDRESS % J� CITY/STATE/ZIP lJGIZLi i� i(�c �'.53�6 <br /> LICENSE W14-42 110C-36 OTHER - NUMBER 4J J EXPIRATION DATE <br /> WATER TABLE DEPTH: ) _ It GEOGRAPHICAL INFORMATION: Coordinates X Y _ <br /> ❑ PERC TEST #_ BUILDING PERMIT# _ LAND USE APPLICATION# 1 <br /> TYPE OF WORK: -1 NEW INSTALLATION ❑ REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> G REPLACEMENT J OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: IVRESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVIN UNITS: NUMBER OF BEDROOMS: ? NUMBER OF EMPLOYEES: <br /> fall� SEPTIC TANK �: TYPE/MFGCAPACITY J2 ire gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL -1 1 -r-.. ft FOUNDATION J ft PROPERTY LINE 10_�_ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES 1 LEACHING CHAMBERS #OF LINES LENGTH OF LINES 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 WFLL 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 /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION 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 LIC[:-NSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 20 2OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 <br /> SIGNED t TITLE 114A DATE 42:7/ <br /> GnP r <br /> el <br /> 1 <br /> a <br /> b � <br /> y NT <br /> ti 1 <br /> 2018 <br /> -t J A <br /> IR N E TANTy <br /> RNENT <br /> EPARTMENTUS O LY <br /> Application Accepted By Date t Area Employee ID#� <br /> Final Inspection By Date 2� ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to De of 3 Ft: Pit/ ump Soil Character: <br /> COMMENTS DULA NPYt-vuIyis E1L rz()oaQLIQ Ca-DCLUN_¢� <br /> W WM PUJ 1(1, at k A IYIQ, l LtW <br /> PE SC - Received Che Amount I Permit/ <br /> Code INFO B Cash Remitted Date Service Request# Invoice# Permit ID# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />