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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 pW PERMIT 1 ' -1 GALL 209 953-7697FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS tpw • L1 4N4411Fgp 'b _ c j <br />-CITY/ZIP —MA"` ./- / x377 <br />CROSS STREET L-Vye 0-p'L AD `/0a le � APN _ _ J 3 1 f o o 3 —PARCEL SIZE 'g' &- 7 <br />OWNER NAME PE1-611 .Safi F/IC T l/ _ PHONNE 2 - <br />OWNER ADDRESS %L00 1w' t-1 1vx �T� ���`-� - /STATE/ZIP e4.1 0/4 57.S-:5-" <br />CONTRACTOR eU` E -s i I Map- J L�- rJ PHONE _O /" �� Z /� 95 <br />CONTRACTOR ADDRESS . dX CITY/STATE/ZIP <br />LICENSE ❑ 'C-42 ❑ iC-36 OTHER _.' NUMBER qB57GGa _- EXPIRATION DATE_ <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X _ Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION I I REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT - P OUT -OF -SERVICE SEPTIC SYSTEM X DESTRUCTION � N 91 K <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL I OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG _ _._. CAPACITY _ <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES Fl LEACHING CHAMBERS # OF LINES <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ FILTER BED WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE It <br />❑ MOUNDED WIDTH ft LENGTH _ _ <br />ft DEPTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />It PROPERTY LINEft <br />4-11 it <br />❑ SUMPS WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />DISTANCE <br />ft PROPERTY LINE `j ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH SAI, ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />w <br />ft PROPERTY LINEENVIRn...N COUNTvft <br />�iEALT'H <br />DEP,- <br />L1 SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />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 <br />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 />YLYMM 2.ALR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />U <br />SIGNED /`� TITLE_ <br />DATE <br />DEPARTMENT USE ONLY /� <br />Application Accepted By Date �- Area S Tri y Employee ID# A h ilr,,l <br />Final Inspection By Date �� I I SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: -__ Pit/Sump Soil Character: _ <br />COMMENTS Qe in c2 AC)wj <br />PE <br />Code <br />SC <br />INFO <br />Received <br />Check <br />- ash <br />Amount <br />Remitted <br />D to <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />