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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 /> NI,@N-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 934 N Y CITY/ZIP <br /> Ci1OSS STREET Q APN 007-10-70-15 -PARCEL SIZE G <br /> PHONE gam <br /> OWNER NAME / CJItiI ���yyY,,� p� <br /> OWNER ADDRESS a3<—W Ifu �"'` CITY/STATE/ZIP <br /> CONTRACTOR KTP V -t�, PHONE <br /> CONTRACTOR ADDRESS / 030 '�• CITY/STATE/ZIP �l <br /> LICENSE ❑XC-42 ❑❑C-36 OTHER NUMBER O 7 EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT#-, LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION i ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE I_I COMMERCIAL I� OTHER <br /> 9L <br /> NUMBER OF LIVING UNITS: j NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG I S?7►7q 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 C LENGTH OF LINES 557 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE /O ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL it 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 /> l SEEPAGE PITS NUMBER a WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ISO ft FOUNDATION 3o ft PROPERTY LINE Id 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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 <br /> SIGNED TITLE r DATE <br /> �J <br /> ----A�±E <br /> C- <br /> H 1 <br /> —RUA MD— <br /> SAN MMW=Xrf� <br /> EA <br /> 1 <br /> T D P T E T <br /> EPARTMENT 0.13EO LY <br /> LZ <br /> Application Accepted By Date Area . Employee ID#� <br /> Final Inspection By �d�/-'^'" Date 4 ❑ SPECIAL PERMIT-Approved by <br /> Character of Sol[to Depth of 3 Ft: _ Pit/Sump Soil Character: <br /> COMMENTS _ _ <br /> PE SC Received ChecKV <br /> Amount Permit/ <br /> Code INFO B Cash itted Date Service Request# <br /> .Code <br /> # Permit ID# <br /> 2� 201 n S( <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />