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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> ISAN 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 XPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS C6 V/ CITY/ZIP ; 2- <br /> CROSS <br /> CROSS STREET APNl� '©Y OI O PARCEL SIZE V' <br /> d <br /> OWNER NAME_ ""'' �� 't"v PHONEAPn <br /> /% \ v� <br /> OWNER ADDRESS C/ U��� CITY/STATE/ZIP [ -P <br /> 2-0 CONTRACTOR �C ryR rg �ns/'/�,V��/I^^ //ter PHONE <br /> CONTRACTOR ADDRESS �J7y`� �t./tJ4 J--rel `f . CITY/STATE/ZIP <br /> LICENSE C-42 C-36 OTHER NUMBER EXPIRATION DATEIF <br /> / <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I NEW INSTALLATION I REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: ESIDENCE COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: ,,^/NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG i `i14/> CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE _ TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES LEACHING CHAMBERS #OF LINES q f LENGTH OF LINES G ID It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION �^' ft PROPERTY LINE ��/ ft <br /> ❑ FILTER BED WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH It LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE It <br /> ❑ SUMPS WIDTH It LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> SEEPAGE PITS NUMBER WIDTH .30ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE /A 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 � DATE 3� <br /> il <br /> � c , <br /> Sq <br /> T <br /> EPA RTMEN US ONLY <br /> Application Accepted, y Date Area —� Employee ID# <br /> Final Inspection By Date Q:112 5A 9 1 SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS �1i0���/ <br /> PE SC Received (-,gpeck#13 Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> I(o 1131119 cM0MIAW <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />