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I � T <br /> 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 y� CALL 209 953-7697 FOR INSPECTIONS �EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP 6 <br /> CROSS STREET APN�i(/ V b PARCEL SIZE C <br /> R ' <br /> OWNER NAME UL Z�D V/1 r Y^ <br /> PHONE � <br /> OWNER ADDRESS Cid/ r _CITY/STATE/ZIP <br /> CONTRACTOR— ��� f «fe PHONE ' 7L 74 A <br /> CONTRACTOR ADDRESS C7iJX `y s CITY/STATE/ZIP 041r_ �V_lcIf- 14.4. 4)111'3CL <br /> LICENSE C-42 I_IOC-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> h PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: ) RESIDENCE COMMERCIAL <br /> OTHER <br /> NUMBER OF LIVING UNITS: l NUMBER OF BEDROOMS: 1-9 NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG 7 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 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 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 FOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)9;{53-7697 <br /> SIGNED �&� TITLE Z-VA DATE C <br /> FfATfntANT <br /> U9, AEGIWED <br /> I 1 <br /> — — -— — - — AaL NTY <br /> L <br /> 1 11 EAT DEPARTMENT <br /> DEPARTMENTU EN Y <br /> Application Accepted By Date Area Employee ID# <br /> Final Inspection By gCUAA_ % <br /> Date Z l SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS /SlY� <br /> ti <br /> PE Sc Received heck Amount Permit/ <br /> Code INFO B Cash emitted Date Service Request# Invoice# Permit ID# <br /> 12M 12, <br /> dll <br /> S <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />