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• ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> S"*N JOAOUIN COUNTY ENVIRONMENT9L tjEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL'209 953-7697 FoR INSPECTiUNS EXPIRES 1 YEAR FROM DATE ISSUED <br /> t— -- - <br /> JOB ADDRESS _ / CITY/ZIP fJ <br /> CROSS STREET APN v PARCEL SIZE <br /> 0 <br /> OWNER NAMEo e PHONE �Q! / �/� rM <br /> OWNER ADDRESS 5 �/ CITY/STATE/ZIP <br /> CONTRACTOR S G PHONE 7 / Z <br /> CONTRACTOR ADDRESS Aq '9'-z CITY/STATE/ZIP L)G n t/ /- i Ca 9.53/6 <br /> LICENSE 1442 ! C-36 OTHER NUMBER Q 1_V 3� (_EXPIRATION DATE <br /> WATER TABLE DEPTH: / ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> I 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: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVIN UNITS: NUMBER OF BEDROOMS:_/ / NUMBER OF EMPLOYEES: <br /> Va SEPTIC TANK()- TYPE/MFG CAPACITY 12 S O gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE I no I t 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 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 /> ❑ 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 LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM�/15 OUR ADVANCE NOTICE REQUIRED FOFI INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE IPAA 4-fie I' DATE <br /> ILL <br /> 0 t <br /> ti <br /> — - - - - - - — — — — - - - - — ro-�6 ' <br /> NO N <br /> DEPARTMENT ALI S Ej ON-L Y HEALTHY>����� <br /> Application Accepted By Date ( ?,1(-7d Area Employee ID# L <br /> Final Inspection By Date 2 Ll SPECIAL PERMIT-Approved by <br /> Character of Soil to De h of 3 Ft: ittSu p Soil Character: <br /> C MENT AAO" L41Y 919Ait�k P61 7;M <br /> 21'zj5p n af- <br /> 21 <br /> 2 '01A <br /> PE SC Received rheck Amount Permit/Code INFO B s Remitted Date Service Request# Invoice# Permit ID# <br /> Z O L-PJ g,5- _*2 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />