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y. ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN BOUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUND BLE PERMIT //CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ZT1 07 A- CITY/ZIP <br /> D304- <br /> CROSS STREECO, A u OI`-45 f10 APN ZM~ I%0 V Y4_0 PARCEL SIZE <br /> OWNERNAMEI /p/N � �`�� �I� / PHONF��46 9$5L m <br /> OWNER ADDRESS /�--7q to I a,1A 67r CITY/STATE/ZIP V536 <br /> c 6 - 0 <br /> CONTRACTOR PHONE <br /> 77 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP `^ /5��V5�5 <br /> ` <br /> LICENSE C-42 I_ C-36 OTHER A NUMBER • 1s"I, EXPIRATION DATE I V <br /> WATER TABLE DEPTH:_i V ft GEOGRAPHICAL INFORMATI oord'nates X Y <br /> FF PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION ADDITION I ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: X RESIDENCE L COMMERCIAL 2 ,0111 OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: J x ` NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION / ft PROPERTY LINE 60 ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> 1 LEACH LINES LEACHING CHAMBERS 00�/2'� ,1` I- #OF LINES 4- LENGTH OF LINES 75 I ft <br /> DISTANCE TO NEAREST WELL 100 ft FOUNDATION 40-t ft PROPERTY LINE 5+ ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION _ ft PROPERTY LINE ft <br /> ElDISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH IYUV niz ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERT44& O ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN A��v�q �Ig ,f�Tl <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUI ��E IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WI RLL <br /> WORKERS COP;PENSAjION LAWS. <br /> 6MAMMM-nuapamm gO ICE REQUIRED FOR TIO - LEASE CALL 209 9,53-74697 <br /> SIGNED /UJUWJJO TITLELkAADATE (' 5 L <br /> 77 <br /> h .. <br /> t 7 <br /> _ � r <br /> f <br /> EPARTM.ENT USN ONLY <br /> Application Accepted By Date Area Employee ID#� <br /> Final Inspection By Date 2 UI ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Mkt of 3 I t Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received 4LhcpW Amount Permit/ <br /> Code INFO Cash emitted Date Service Request# Invoice# Permit ID# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />