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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUND#BL,E <br />P R IT <br />CALL 2 91531769 7 FOR INSPECTION <br />EXPIRES 1 Y O DATE ISSUE[ <br />JOB ADDRESS <br />L'I <br />CITY/ZIP <br /># OF COMPARTMENTS <br />PROPERTY LINE 30 ft <br />❑ LIFT STATION <br />± <br />-0-30 ~ <br />ft <br />CROSS STREET <br />1 Vl Rl <br />APN <br />PARCEL SIZE <br />WIDTH <br />it <br />66 <br />g � ISO 3 <br />OWNER NAME <br />ft <br />U.. <br />PHONNEE�{ <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />OWNER ADDRESS <br />tA <br />C3MOUNDED <br />CONTRACTOR <br />ft <br />n ������CITY/STATERIP <br />Z `" _ Qc_ PHONE 46 <br />6 16 07 <br />0 <br />DEPTH Plvr it <br />CONTRACTOR ADDRESS <br />WELL <br />w"' CITY/STATE/ZIP <br />ft <br />LICENSE AI C-42 <br />❑❑C-36 OTHER <br />A NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: ti ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: ' NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br />X REPLACEMENT Ta n IL , OUT -OF -SERVICE SEPTIC SYSTEM Ji( DESTRUCTION TG /1 IC <br />INSTALLATION WILL SERVE:V4 RESIDENCE [I COMMERCIAL �% 11 OTHER <br />NUMBER OF LIVING UNITS: �_ NUMBER OF BEDROOMS: F+ _ NUMBER OF EMPLOYEES: <br />SEPTIC TANK <br />TYPE/MFG + L <br />CAPACITY I L QU _ gal <br /># OF COMPARTMENTS L� <br />❑ GREASE TRAP <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL czn4 it <br />CAPACITY gal <br />FOUNDATION ) it <br /># OF COMPARTMENTS <br />PROPERTY LINE 30 ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP ❑ <br />PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />❑ LEACHING CHAMBERS <br />heck# <br />s <br /># OF LINES <br />Permit/ <br />Service Request # <br />LENGTH OF LINES it <br />Permit ID# <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />v <br />ft PROPERTY LINE it <br />❑ FILTER BED <br />WIDTH <br />it <br />LENGTH <br />ft <br />DEPTH it <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />--it PROPERTY LINE T it <br />C3MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />it <br />DEPTH Plvr it <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE i A it <br />❑ SUMPS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />It <br />FOUNDATION <br />p�ft <br />it PROPERTY ItVEJO it <br />HF- C it <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />"'/-f <br />ft PROPERTY LINE ' /�77 �a�RT/rHHE ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />_ <br />ft DEPTH it <br />DISTANCE TO NEAREST <br />WELL <br />it <br />FOUNDATION <br />it PROPERTY LINE it <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 />ED FOR INGRECTIONS - <br />DEPARTMENT USE ONLY <br />Application Accepted By Date _]._- % C1 - �_ Area A G% Employee ID# 1�%trh <br />Final Inspection By Date ` L SPECIAL PERMIT - Approved by <br />Character of Soil t .papth 3 Ft Pit/Sump Soil Character: __ <br />COMMENTS �.�✓l�ir ra <br />-1 _ _ / _ L- . <br />s C ar AeckyA <br />PE <br />Code <br />,42-01 <br />v SC Received <br />INFO B <br />heck# <br />s <br />ate <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />42,1 o <br />IS <br />Am�ujn <br />v <br />—115- <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />r. 5/5/17 <br />