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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY 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 O ITY/ZIP <br /> CROSS STREET L APN l.� C I / PARCEL SIZE p <br /> v <br /> OWNER NAME A✓J� IOIG✓U PHONE 7lY 7 ��/I M <br /> OWNER ADDRESS 'A ��/"f/� CITY/STATE/ZIP <br /> CONTRACTOR &4*41 Vo alle O'%l�/� L PHONE C20.9 _�+�7I��/�,a/ / <br /> CONTRACTOR ADDRESS 0 O/JOH Pr- CITY/STATE/ZIP <br /> LICENSE j[:-42 IJC-36 OTHER NUMBER EXPIRATION DATE' <br /> WATER TABLE DEPTH:4 J*11t}df� ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I NEW INSTALLATION REPAIR/ADDITION i ENGINEER DESIGNEE)/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: ' RESIDENCE I COMMERCIAL 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 LINESLEACHING CHAMBERS -5-7Chg berS' #OF LINES 3 LENGTH OF LINES �J� ft <br /> DISTANCE TO NEAREST WELL/00 _ ft FOUNDATION 470 .4ft PROPERTY LINE ,[pT- ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <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 48 HOUR ADVANCEOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL 209 953-7697 G <br /> SI NED TITLE LO/7 �t1/�� DATE 3 dee — <br /> f <br /> Loll <br /> N FW <br /> ivAh ZT* <br /> CALI <br /> ENVIFONmp <br /> HEALTHIDEDARTNENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date ' Ar a Employee ID# <br /> Final Inspection By Date �q PECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft _ <br /> Pit/Sump Soil C acter: - GL <br /> COMMENTS <br /> PE Sc Received Check#/ Amount 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 />