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ONSITE WASTEWATER TREA WENT SYSTEM PERMIT 10/ <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DFPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT > CALL 209 953-gq7697FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JQ! ADDRESS C~ _/ " C/ CITY/ZIP I <br /> EET �IG � APN/o �� O <br /> PARCEL SIZE STR � �J y <br /> "OWNER NAME 1/ 10XII Fr5f 7"z,T � (7 t� PHONE �n <br /> OWNER ADDRESS le W ! �� V��4M-tit CITY/STATE/ZIP <br /> CONTRACTOR � L PHONE <br /> ; ? / JCv —4611/�' <br /> CONTRACTOR ADDRESS 1-�G�/" 57 CITY/STATE/ZIP C✓0/31 <br /> LICENSE ] C-42 I I C-36 OTHER __S,Ji NUMBER 2 ,EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL.INF=ORMATION: Coordinates X Y <br /> PERC TEST # f BUILDING PERMIT# _ LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDU ION NGINEER DESIGNED/ALTERN TIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ 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 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 it 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 4 _ NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 <br /> SIGNED_ f i ' TITLE •�/�G�©� DATE ,:,?, <br /> o1oly <br /> R <br /> 0 <br /> If <br /> Z a <br /> DEPARTMENT USEIONLY <br /> Application Accepted By Date AreaEmployee ID# <br /> Final !nspection By Date C SP CIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: <!► &/1 w AM Pit/Sump Soil Character: _ <br /> COMMENTS VU(�R _�LkA bF KC TAW1 W#:S AfAjAbf� <br /> i1 p n 4-5 L o� VQM A-�¢,f 14 �l��T_10 Tic 02A L . <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO B Cash Remitted Date Service Request# Invoice# Permit ID# <br /> 2 �6 vQDb <br /> 42-01. ONSITE WASTEWATER TR TINT SYSTEM PERMIT <br /> 5/5/17 <br />