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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SA JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> oq �JOB ADDRESS � CmmPyokm3cftC7 <br /> CROSS STREET (�U nCU n Qt". APN 27 1J O / // PARCEL SIZE lq� b <br /> OWNER NAME KC)}1K7 \\ QELx&eyA QUI '� <br /> /'� !�/�(� P h.. PHONE`�97I fJ' 9S-n9o8� � <br /> OWNERADDRESS G299 W r R�Ikn fz0Ari CITY/STATE21P „ 1sqr4�Pc CA y ;;`�- <br /> CONTRACTOR S E u7 PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑❑C42 ❑❑C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# U <br /> TYPE OF WORK: ❑ NEW INSTALLATION REPAIRIADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ OUT-OF-SERVICE SEPTIC SYSTEM ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTICTANK TYPEIMFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASETRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> r <br /> LEACH LINES ❑ LEACHING CHAMBERS #OF LINES I LENGTH OF LINES Q It <br /> l <br /> DISTANCE TONEAREST WELL I t7D ft FOUNDATION — <br /> ��ft PROPERTY LINE Ci( It <br /> ❑ FILTER BED WIDTH It LENGTH It DEPTH It <br /> DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE It <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ,r <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE Ibr=. <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH Pr'�-n .., ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINEQ' <br /> ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH— C. ft 11A, O�ftjy <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTYLINE HSI VIN/yAii N-TaL <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN EN <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 /> MINIMU 46 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697q <br /> SIGNED TITLE DATE <br /> u <br /> ft 4 <br /> No ARTMENT S ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Final Inspection By Date El ;PE IAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 F Pit(Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permltl Invoice# Permit lD# <br /> Code INF o ash Remitted S rvice usst# <br /> S� zoo 1 <br /> I - 7 <br /> '0114, aadillm,- <br /> 515/1 / "�L1.1- 4'$I,O'-]7GJ� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 l,El 1 / t / <br />