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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 />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS a[ `%• C /.� -!"r^ j_ '.f _ � � s_ _ _ _CITY21P " rr" <br />CROSS STREET APN ^ d /�/' <br />..[ � 1 PARCEL SIZE d <br />OWNER NAME ---PHONE <br />1<[,rf ___PHONE <br />OWNER ADDRESS G, v Iw r rG �� L ►1 _ _ _ _ _ _ CITY/STATE/ZIP S G ID <br />I\ I� J CA C I, (A q 4 g,, 5 <br />CONTRACTOR SCk P. -N-2_ � G°� _ _ _ PHONE 2_00 91y 973!3-- <br />CONTRACTOR <br />173CONTRACTOR ADDRESS 1193Q _rARCx= COY^ .CITY/STATE/ZIP\ K�[�4 C�CAA gsj 5 (� <br />LICENSE LII C-42 ❑ i 1C-36 OTHER _ NUMBI <br />ER EXPIRATION DATE /"^' ` <br />WATER TABLE DEPTH: N / i t It GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # <br />Received <br />B <br />BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION_ REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT — OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION TG I IL <br />INSTALLATION WILL SERVE: f_t�L RESIDENCE 1 I COMMERCIAL,, I I OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: ii_1 NUMBER OF EMPLOYEES: <br />d <br />35 SEPTICTANK TYPE/MFG _'\__,^QY-,Cfe_-C�— _ CAPACITY et gal44, FITMENTS <br />Ll GREASETRAP TYPE/MFG _ CAPACITY g ���### <br />0 <br />DISTANCE TO NEAREST: WELL CGMflAV1h i ft FOUNDATION 5 NE ft <br />E3 LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT L3SAND OIL SEPA D SYSTEM) <br />❑ LEACH LINES iJ LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION It 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 It 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 -24 HOUR ADVANC113MMOMP FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />�VJL__ /2 ^ <br />SIGNED �T�'�- �/ TITLE_. _�W r%, 16,111 DATE /Z - <br />Application Accepted By Y <br />Final Inspection By <br />Character of Soil to Depth of 3 Ft: <br />COMMENTS I -10 t' <br />DEPARTMENT USE OUY <br />Date I Area C Employee ID# <br />Date_ ❑ SPECIAL PERMIT - Approved by <br />Pit/Sump Soil Character: <br />FAVIVOMA <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Check# <br />ash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />ermit ID# <br />�;L <br />I <br />33o <br />JLRy <br />TRIFIA <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />r <br />