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ONSITE WASTEWATER TINEA WENT SYSTEM PERMIT <br /> $AN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1$68 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)486.3420 <br /> MON-REFUNDA,�rB�Lr�E��PERMIT _ CALL 209 9513-7697 FOR INSPECTIONS EXPIRES 1�YEAR <br /> �FROM DATE ISSUED <br /> Jos ADDRESS�^�..L_§ ✓Z, ./(� /5✓'% it �!7�j.:._(7tS __Cm21P,.,_A4'V-4e.MA 'S l2- :2�' `L <br /> a -- - <br /> g y <br /> CROSS STREET ._,...._._� .__._APIC, V -__..__........__...�PARCEL SIZE op <br /> FR <br /> OWNER ' ._..._._..__..�.._.....�___. ..._..PHONE "" <br /> OwNm ADDRESS 1AAY __...__..._._._ CITYISTATFJZIP * <br /> CONTRACTOR/ (��ip � ✓l,I~ J / Y_X L PHONE1�L�" <br /> CONTRACTOR ADDRESS � s�-'T/-_.,lS r y,-� _.._..._..._-_.-._CrTYISTATEILIP <br /> A } ,I Cr ��wT✓ <br /> LICENSE AT-IC-42 ,...CC-36 OTHER kd NUMBER, , EXPIRATION DATE1-i <br /> WATER TABLE DEPTH: Ito'v- Izo, —ft GEOGRAPHICAL INFORMATION: COO! mates X_ Y <br /> ❑ PERC TEST #_ I BUILDING PER # , .-,�, LAND USE APPLICATION# <br /> TYPE OF WORK: r NEW INSTALLATION FrEPAIIVADDITION u ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT _ OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: ! RESIDENCE L'I COMMERCIAL LI OTHER. <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS;_ NUMaER OF EMPLOYEES: <br /> SEPTIC TANK TYPEIMFG CAPACITY ; -OZ90 gal #OF COMPARTMENTS <br /> D GREASE TRAP TYPEtMFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL _ it FOUNDATION / ft PROPERTY LINE /P_;'4- It <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ..._0 PKG TX PLANT 0 SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> rte_,LEACH LINES LEACHING CHAMBERS _ #OF LINES LENGTH OF LINES EJ/ , It <br /> _ DISTANCE TO NEAREST WELL,.,.,�.LC1�-.'Z�„ It FOUNDATION- ._It PROPERTY LINE �,'•,aY It <br /> D FILTER BED WIDTH ._it LENGTH_- _•_� ft DEPTH it <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ._ft PROPERTY UNE It <br /> D MOUNDED WIDTH ft LENGTH ft DEPTH. ft <br /> DISTANCETONEAREST WELLit FOUNDATION, _..__ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH �.ft LENGTH^_ -ft DEPTH ft <br /> DtSTANCE TO NEAREST W ELLit FOUNDATION It PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS (MOTH___ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL _ It FOUNDATION _it PROPERTY LINE ft <br /> SEEPAGE PITS NUMaER___A5� WIDTH_-1 /._ __. fl DEPTH�i Cr- 7 ft <br /> DISTANCE TO NEAREST WELL_Z_-� ft FOUNDATION�p -_'.fl PROPERTY UNE 'fi 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 /> MIN24 HDU DV CE NOT7CE REQUIRED FOR INSPECT7IONS-PLEASE CALL 209 953-7597 <br /> $1 NED TITLE DATE <br /> J <br /> � o <br /> Iw- <br /> If <br /> e <br /> EPA RTMENTU D L _ <br /> Application Accepted By _ Date.., ___ Area f Employee ID#�- <br /> Final Inspection 8 Date_., tt 4PP Y <br /> p y /Jy y U SPECIAL PERMIT• ro ad b <br /> Character of Soil to Dap f 3 T.. �_. '. Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/ Amount '' Perm W Invoice# Permit ID# <br /> Cods INFO B yy, Cash Remitt6A Datc Service Ra uest# <br /> 42-01 -7 t �gZ! i ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5!5177 <br />