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z <br />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 C L -ALL ZUY .9b3-1139/ FOR INSPECTIONS LXPIRES 1 YEAR FROM DATE ISSUE[ <br />JOB ADDRESS L'LM ` ` a � CITY21P ( L,.JC! CA - <br />CROSS STREET l3 ' APN / 1 ' D PARCEL SIZE • S L <br />OWNER NAME 7:5V v/%�� PHONE ) ( S— 6354 <br />OWNER ADDRESS <br />/� ./ rN C (' S �� J lb'�C <br />CONTRACTOR r V V 1 C0AS1 1(5A CLrLAaU- I P - <br />CONTRACTOR ADDRESS Yz' <br />ITY/STATE21P `(`� <br />PHONE �� )/ <br />-CITY/STATE/ZIP L"3, I u) C) <br />LICENSE I C-42 1 I C-36 OTHER Q NUMBER B S t 1 3-1 EXPIRATION DATE ?-J 'L -3 <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: <br />PERC TEST # BUILDING PERMIT # <br />Coordinates X Y <br />LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM <br />DESTRUCTION <br />INSTALLATION WILL SERVE: ,(�._ RESIDENCE L1 COMMERCIAL L_I OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />TERNATIVE <br />❑ SEPTIC TANK TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />_.)U <br />❑ LEACH LINES LEACHING CHAMBERS ��^/` <br /># OF LINESLENGTH OF LINES ft <br />ft ,�� PROPERTY LINE ft <br />DISTANCE TO NEAREST WELL <br />Jq FILTER BED WIDTH a O ft <br />✓� FOUNDATION <br />LENGTH /13 It DEPTH 901" ft <br />DISTANCE T^ NFARFST WELL <br />S_D f ft FOUNDATION h t ft PROPERTY I LNE S ft <br />❑ MOUNDED WIDTH _ ft <br />LEN(TH fL DEPTH _ It <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION _ ft PROPERTY LINE ft <br />❑ SUMPS WIDTH ft <br />LENGTH ft DEPTH its ;a ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH ft <br />LENGTH It DEPTH n ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPE TY LIN ft <br />?0 <br />WIDTH ft DEPTHS ft <br />LJ SEEPAGE PITS NUMBER <br />_ <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PRO ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCOR SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED 'LlIS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS <br />STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WI ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 48 HOUR ADVANCE NOT[ <br />OUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />?' 64-1 I -j— Z - <br />SIGNED <br />TITLE DATE %L' <br />DEPARTMENT USE QNLY <br />Application Accepted By �� DateIt <br />0 Area 3%f'� Employee ID#.�� <br />Final Inspection By Date Ll SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: Pit ump Soil Character: <br />COMMENTS FAJOIsysirM. ,s?I`ne IiD re 11 , e t2 F 10AI M I <br />Of we lls � ,", *' erj jeejtA I,�IeS Ii v,le ��c ry be plus �ePf �r �.vt ���I r baF'.sd <br />PE SC <br />INFO <br />Received c <br />B s <br />Amount <br />Remitted <br />Date <br />Permit/Code <br />Service a uest # <br />Invoice # <br />Permit ID# <br />air )s <br />_.)U <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />