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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAP,l J'IAOUIN,COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> N"ON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 3 7 W' I D CITY/ZIP Rl1fqo3 <br /> ! � <br /> CROSS STREET ����M erd APN _ I G PARCEL SIZE 3. 6q+jJ p <br /> OWNER NAME &�( 14 1�1 �� 6- �/i I^6{S _ PHONE m <br /> OWNER ADDRESS 1335/ k)- Q-0A.d _CITY/STATE/ZIP � <br /> CO' /-ITRACTOR q k a-(YnV ISI✓Cif�k, PHONE 2 u9 ;?O3' <br /> CONTRACTOR ADDRESS qj9 CITY/STATE/ZIP <br /> LICENSE ❑ C-42 ❑ C-36 OTHER A NUMBER 6426 7 EXPIRATION DATE 1431:914019 <br /> WATER TABLE DEPTH: / ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# O LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM Ll DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE L11'COMMERCIAL K OTHER <br /> NUMBER OF LIVING UNITS: O NUMBER OF BEDROOMS: 0 NUMBER OF EMPLOYEES: <br /> 5 SEPTIC TANK TYPE/MFG �Q h S e 11 S Z-Ll 00` CAPACITY Q & 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 /> Q� 1 <br /> I( LEACH LINES L LEACHING CHAMBERS #OF LINES v LENGTH OF LINES It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION _ft PROPERTY LINE ft <br /> Ly FILTER BED WIDTH 33, <br /> 1 It _ It LENGTH loot` 711 <br /> ft DEPTH 3 / ft <br /> DISTANCE TO NEAREST WELL I UCJ it FOUNDATION S U x ft PROPERTY LINE It <br /> ❑ MOUNDED WIDTH ft LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ SUMPS WIDTH _ It LENGTH __- It DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH—_ _ _ ft DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It <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 HW ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE <br /> --1AAI Th <br /> E• Q / <br /> Ty M y <br /> r <br /> KTiVENT USE 0INL <br /> Application Accepted By Date—_ 1' ; -/-? Area — Employee ID# Ah I'yl( <br /> Final Inspection By Date_-_I-� a�— ❑ SPECIAL PERMIT-Approved by <br /> Character of Sall to Deg of 4tom_S'1d►T __ Pit/Sump Soil Character: _ _— <br /> COMMENTS <br /> PE SC Receivedec Amount ' PermiU <br /> Date Invoice# Permit ID# <br /> Code INFO B �'C�sh Remitted Service Request# <br /> ? 1 <br /> 42-01 ON51TF WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />