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Jag3q CAI PO.Ck <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />,%SAN QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON -R UNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />OB ADDRESS ` 7­4CITY/ZIP'. <br />s���1J1�✓ty 1� J 4U6 <br />CROSS STREET A P N ll / r -2 ' PARCEL SIZE —0(2 <br />OWNER NAME ��� V4:_ PHONE70q �LIS <br />OWNER ADDRESS ?/�J� W V�/ �g�1 —CITY/STATE/ZIP <br />c4'nl <br />CONTRACTOR r 1 /V M'�/�''� �I/iI l lCu� PHONE <br />CONTRACTOR ADDRESS l/1'�'�W�7 ,+1/1 ` CITY/STATE/ZIP �/r�`� 1 �? <br />LICENSE I I IC -42 [II IC -36 OTHER (� l NUMBER q01 I3" EXPIRATION DATE1( <br />`^ <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: <br />PERC TEST # BUILDING PERMIT # <br />TYPE OF WORK: I NEW INSTALLATION I REPAIR/ADC <br />Coordinates X <br />LAND USE APPLICATION #. <br />)N f I ENGINEER DI <br />Y <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: CI RESIDENCE I COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />❑ LIFT STATION SIZE TYPE OF PUMP <br />TERNA <br />CAPACITY gal # OF COMPARTMENTS <br />CAPAC gal # OF COMPARTMENTS <br />ft FOUN TTk�ft PROPERTY LINE ft <br />❑ P T A IL SEPARATOR (ENCLOSED SYSTEM) <br />kip_ <br />❑ LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />❑ MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />❑ SUMPS <br />WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />OF LINES <br />ft PROPERTY LINE <br />It DEPTH <br />ft PROPERTY LINE <br />ft DEPTH <br />ft PROPERTY LINE <br />ft DEPTH <br />ft PROPERTY LINE <br />ft DEPTH <br />ft PROPERTY LIIV <br />ft DEPTH <br />ft PROPERTY LINE <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 <br />SIGNED ��–� TITLE d{&'L 44p- DA <br />Application Accepted By,1z_A <br />Final Inspection By <br />Character of Soil to Depth of 3 <br />COMMENTS <br />Date L,,'/1 Area -,;� <br />Date V , / /_1.1 Sk <br />Pit/Sump Soil Character: <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />Employee ID# A~ <br />PERMIT - Approved by <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />