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ONSITE WASTEWATER Tnir-ATMENT SYSTEM PERMIT <br /> SAN JOAQL'1,4 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT i868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NO,N-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS �ExPIRR_ESS 1.YEAR FROM <br /> DATE ISSUED <br /> Jo ADDRESS - r CITY/ZIP Ci1��TV 7 <br /> CROSS STREET ' /i J APN , L4 .S /�0 `�-S PARCEL SIZE 0, <br /> 0 <br /> OWNER NAME �7.3 <br /> 7 _ PHH0ME 112a <br /> OWNER ADDRESS G '2JC� �' CITY/STATE/ZIP S P�-��� <br /> CONTRACTOR __ PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-42 C-367 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: o-3 t) ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> J PERC TEST # f BUILDING PERMIT# _ LAND USE APPLICATION# <br /> TYPE OF WORK: J NEW INSTALLATION REPAIR/ADDII[ON ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM l( DESTRUCTION 'Si <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL ' OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 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 -- It PROPERTY LINE _ It <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It 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 ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH_-_ ____ft DEPTH ft <br /> DISTANCE TO NEAREST WELL _ ft FOUNDATION 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 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 /> MIrTllr_'� <br /> UM 24 HOUR NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED - TITLE_ ��.� /!C!- _ DATEC: C;W0/1 <br /> G <br /> J P E N <br /> E <br /> N <br /> PrPA_RTA USE ONLY <br /> Application Accepted By Date - Area I /� Employee ID#Cs <br /> S<< f <br /> Final Inspection By Date Z� 1 D SPECIAL PERMIT-Approved by <br /> Character of Soil to Dept of 3' Pit/Sump Soil Character: <br /> C MENTS 6,Gri rk f r, o 4d S e wpm <br /> G Ql GZ <br /> � s <br /> PE SC Ileceived rCheclo# Amount Permit/Code INFO B sh Remitted Dae Service Re uest# Invoice# Permit ID# <br /> y� 17 If <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />