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1 � <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOPQ6N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT r (� CALL(209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS l i V / 1 l�+� \, c s'.I'��� CITY/ZIP <br /> CROSS STREET APN v PARCEL SIZE 3, 1 <br /> OWNER NAME `��' PHONE <br /> yy <br /> OWNER ADDRESS ✓A{Y`� � CITY/STATE/ZIP <br /> ?� Z <br /> CONTRACTOR i, EST CDM_1 ���r��� , �Jam( � PHONE d J� / -7J /L� <br /> CONTRACTOR ADDRESS �t A LL j o 1 51(CL-r 1-00-1 CITY/STATE/ZIP ^ C^ �J�-I b C/' <br /> LICENSE C-42 C-36 OTHER_A� NUMBER SSIX S-7 EXPIRATION DATE 5 <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y �f <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# j <br /> TYPE OF WORK: j' NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE I I COMMERCIAL OTHER" <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: C <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY <br /> gal #OF COMPARTMENTS__ <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY ^� gal #OF COMPARTMENTS <br /> DISTANCE To NEAREST: WELL ft FOUNDATION �y ft PROPERTY LINE S ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LJLEACH LINES )k LEACHING CHAMBERS 1 I A-7.3 � #OF LINES_L4 LENGTH OF LINES 21 ft <br /> DISTANCE TO NEAREST WELL 1 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 WIDTHt ft DEPTH 2S ft <br /> DISTANCE To NEAREST WELL 15Z 1 ft FOUNDATION J '� ft PROPERTY LINE S 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE TCLS�0��7 DATE4y <br /> I <br /> Md <br /> ESA <br /> O U Al A <br /> N _UuAlre <br /> RM <br /> J / DEPARTMENT USE ONLY l <br /> Application Accepted B Li[ _ Date U Z�Z Area q b ! Employee ID# JV �fe� <br /> Final Inspection By _ Date I SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: r <br /> COMMENTS 1jer nek'j It Sfril a SEE. /Jo �jeils will,in 700 fmf per &HD Ilecor <br /> note • 1-nspr-1 ion is ✓e„FlyJell Or;fr4 wGe of r�r;�H bf .p,o�Frly, <br /> PE Sc Received Check Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By s Remitted Service Request# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />