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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 fes' EXPIRES 1 YEAR FROM DATE ISSUED <br /> 6JOB ADDRESS L� S U6 KA CITY/ZIP <br /> 1P �.��1 l V�� `-5-32- <br /> CROSS <br /> 53 -CROSS STREET �,a�lscYa\> ! 2(� APN PARCEL SIZE - o3 p <br /> v��.\ / U <br /> 1�-�GV I I LJ L Y Y�}'� PHONE 1 ZS <br /> OWNER NAME t <br /> OWNER ADDRESS �hl�lf�i CITY/STATE/ZIP <br /> CONTRACTOR stl:)-,� PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE I I C-42 I I C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: 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 i ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION <br /> INSTALLATION WILL SERVE: I I 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 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 NILCI r <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE t <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH t <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH SAN ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIEN eu IRn�n��.C�VAITYft <br /> R�7R' .� <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE Wlgwi kr <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 R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE 1-C(A - nLsJl DATE 3-28-13 <br /> PARTMENTUSE NLY <br /> Application Accepted By Date Area Employee ID# <br /> bwf& <br /> Final Inspection By /046bDate F1 SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Chec Amount Permit/Code INFO ash emitted Date Service Request# Invoice# Permit ID# <br /> 2g 14 S on0A <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />