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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAnUIN COUNTY ENVIRONMENTAL HLALTH 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 r r CITY/ZIP I <br /> CROSS STREET LGL`' !!` APN PARCEL SIZE �DS <br /> d <br /> /� v <br /> OWNER NAMEi3 N1 <br /> PHONE 9`� G/+ <br /> OWNER ADDRESS POP CITY/STATE/ZIP ' 1 <br /> CONTRACTOR ► I k' PHONE_ <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-42 C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED IALTERNA VE A <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION j <br /> INSTALLATION WILL SERVE: I-1 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/MPG _ — 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 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 �s <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTHCIIApt <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINES ' q� AZJ�fO <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH P 7gnen It <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE r.'/flAQ�„� It <br /> ❑ SEEPAGE PITS NUMBER _ WIDTH ft DEPTH HiROAIA,V C IJk-.ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE gRt�.,q 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 ADVA CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 / <br /> SIGNED — "lit: TITLE DATE <br /> DEPARTMENT USE ONLY � lJ <br /> Application Accepted By Date Area _�V r 11 <br /> Employee ID# <br /> Final Inspection By ' Date I SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS S l S <br /> a <br /> PE SC Received Check Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Remitted Service Request#. <br /> 2 I <br /> 42-01 V I "j A�yy, ONSITE WASTEWATER TRTMNT SYSTEM PE1YII I t"J <br /> (qv' <br /> 5/5/17 <br /> AA <br /> C �J�C/ �✓� <br /> a <br />