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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> KION-REFUNDABLE PERMITS 1 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM M DATE ISSUED <br /> JOB ADDRESS ^ tr`�S0 tx ora S� CITY/ZIP q c, <br /> CROSS STREET LOS �,♦v`tAPN�7` O� ' PARCEL SIZE B- <br /> ,T O <br /> ,gyp` C _(A' v <br /> OWNER NAME �} V \J1l` \ t©Z.� PHONE L �.iJ 1 J�Jb <br /> OWNER ADDRESS ��('nC_ CITY/STATE/ZIP <br /> CONTRACTOR Se PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-42 I C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> 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: 1 1 RESIDENCE ❑ 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 13A%r �ft <br /> L3 �j . <br /> FILTER BED WIDTH ft LENGTH ft DEPTH - I�V I ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE f <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH Wo ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 18 ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ` NJOA n, ,_ _ ft <br /> fzi7GIRONMEN"n f rt <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIWA �.._ �� <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH � E�MENrft <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 /> MIN MUM r OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE f Y k V, - DATE _C 4 I Ly ` I b <br /> a <br /> 41 _qA. PARTMENT_USE_jd1VLY <br /> Application Accepted By Date Area Employee ID <br /> Final Inspection By Date ❑ SP CIAL ERMIT-Approved by <br /> Character of Soil t Depth 9f 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS -%, I le-10 <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO B Cash flemitted Date Service Request# Invoice# Permit ID# <br /> Z v 7_ 1ISR_OL790317 <br /> 42-01L ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />