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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PLERMI,T1 CALL 209 95 97 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP �� yo <br /> w <br /> CROSS STREET /��/C / — APN t/D�'-1 / O PARCEL SIZE <br /> v <br /> v <br /> OWNER NAME4Y,1'ar.� PHONE <br /> OWNER ADDRESS Z LcJy'3 )�� �usc ca"� ,t»� CITY/STATE/ZIP <br /> 7 <br /> CONTRACTOR ��f� /�G //// /7� PHONE <br /> CONTRACTOR ADDRESS �3��i �1SG^� )� CITY/STATE/ZIP <br /> � c <br /> LICENSE LI�-42 1 11 'C-36 OTHER NUMBER L/ p EXPIRATION DATE <br /> WATER TABLE DEPTH: L/y �J 0 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I NEW INSTALLATION I REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM ESTRUCTIONici� <br /> INSTALLATION WILL SERVE: RESIDENCE I I COMMERCIAL I OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG 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 1_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 WELL ft FOUNDATION ft PROPERTY I- ft <br /> ❑ MOUNDED WIDTH it LENGTH ft DEPTH I ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY Eby ft <br /> ❑ SUMPS WIDTH It LENGTH ft DEPTH __����''"""" t[� f ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROP?ft E / ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ENV x/99 UlN ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY�Kf�A, NAL ft <br /> J��FNT <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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 <br /> SIGNED TITLE�.�/ DATE <br /> A <br /> DEPARTMENTIUS&I ONLY <br /> Application Accepted y Date Area Employee ID# <br /> Final Inspection By, Date 2. F1 SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received h Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO ash Remitted Service Request# <br /> ,-Z-306 SZ 2 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />