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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 CA 4L 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR <br /> FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP L./ <br /> 4-1 <br /> CROSS STREET APN 1]3-2a90--0410 PARCEL SIZE t3310 <br /> 10 y <br /> OWNER NAME S7 CWL PHONE65-0-!A I- c)MX O m <br /> OWNER ADDRESS 6 ITY/STATE/ZIP <br /> CONTRACTORDIA . I G PHONE <br /> 'RAA-1r, <br /> �)6 C)7 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP CAt C4 5 20 <br /> LICENSE y C-42 I I C-36 OTHER A NUMBERV005 W EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> U PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DES GNED/ALTERNNAT�IVE. <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM `� DESTRUCTION 1/��✓` <br /> INSTALLATION WILL SERVE: X 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 LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <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 pAxe, ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE D <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH APR- ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE U Z 9t <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH � AQUIA, ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE'�I.TH n NMFNTe, <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN T <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 COMPENS�ION LAWS. <br /> M V H U I REQUIRED FOR IffSP,1kU10Nar PLEASE CALL (209) <br /> ''3--7697 <br /> SIGNED TITL DATE �l <br /> Q: L #rn. 4 <br /> fie` <br /> { A <br /> < �`' <br /> _ y <br /> IL <br /> IN <br /> OIL n IL IAL <br /> j <br /> E ARTMENTdSEIONLY <br /> Application Accepted By Date fl Area Employee ID#�l/� <br /> Final Inspection By Date ❑ SPE IAL PERMIT-Approved by <br /> Character of Soil to D th of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTSAl. V0 AAA1 At- finspt2 Ar <br /> r <br /> PE SC Received ec Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO Remitted Service Request# <br /> Z, �u p <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />