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UN511 t WAS 1 tWA 1 tH I HEA I MENT SYSTEM PERMIT <br /> 3AN JOAOUIN COUNTY ENVIRONMENTAL HEALTH 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 <br /> v <br /> ;ROSS STREET APN n Q� 101 G - c SL __ �L 17. PARCEL SIZE v <br /> OWNER NAME _PHONE f; <br /> OWNER ADDRESS / n�A'I�j _ __.____CITY/STATE/Z1P �!_ � lO� L , <br /> :ONTRACTOfl r �'!l r,/ -/ Q y�,�i/ <br /> �.� �. .�L�-�J�rY -- _----_.._____.. PHONE_ZL0 /�'��/---)fX+-.l <br /> CONTRACTOR ADDRESSQ <br /> .ICENSE ❑ C42 U C-36 OTHERNUMBER ?, EXPIRATION DATE_____�" <br /> WATER TABLE DEPTH: II -ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> Li PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> 'YPE OF WORK: NEW INSTALLATION REPAIR/ADOtTIDN ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION S�sraj�'7,.JrC <br /> INSTALLATION WILL SERVE: I. RESIDENCE i 1 COMMERCIAL I 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 It FOUNDATION It PROPERTY LINE It <br /> 7 LIFT STATION SIZE TYPE OF PUMP _ _❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS #OF LINES _ LENGTH OF LINES If <br /> DISTANCE TO NEAREST WELL it FOUNDATION h PROPERTY LINE It <br /> ] FILTER BED WIDTH __It LENGTH____ __ ft DEPTH ft <br /> DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE It <br /> ❑ MOUNDED WIDTH ._ ..__It LENGTH _ ft DEPTH it <br /> DISTANCE TO NEAREST WELL _ h FOUNDATION ft PROPERTY LINE ft <br /> 3 SUMPS WIDTH _ it LENGTH— __ it DEPTH it <br /> DISTANCE TO NEAREST WELL _ h FOUNDATION ft PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH _ ___ It LENGTH _ h DEPTH It <br /> DISTANCE TO NEAREST WELL _ It FOUNDATION it PROPERTY LINE ft <br /> ] SEEPAGE PITS NUMBER ____ WIDTH —_ _h DEPTH ft <br /> DISTANCE TO NEAREST WELL _ ft FOUNDATION— it 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 /> 'OAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> ;URRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> VORKERS COMPENSATI N LAWS. <br /> MINIMUOUB,4VAgCDkTICEREOUIRED FOR INSPECTIONS-PLEASE CALL(209)253L69 <br /> SIGNED C- TITLE_ { — DATE <br /> r 17 <br /> N" <br /> T <br /> DEPARTMENT USE ONLY , <br /> Application Accepted By _ <br /> Dale _ -_ Area C! Employee ID# won y <br /> Final Inspection By __V Date__[G_ L, SPECIAL PERMIT-Approved by <br /> ;haracter of Soil to Depth ofA Ft: Pit/Sump Soil Character: <br /> ;OMMENTS—CC Mrticr<;Ctbe ,r's G��nlol ;sr1c�' P!/ IS <br /> e;r` 1 frrr r!;5 r 1, <br /> PE SC Received Chec Amount Data Permit/ Invoice# Permit ID# <br /> Code INFO B ---'Msh Remitted Service Re u t# <br /> 07S lz�� I 1SW7 12_�_�j�go-jyjj q" <br /> 2-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />