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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT UP <br />SAS JO/ QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />EFUNDABLE PERM <br />GALL (2U.9).953-1691 FOR INSPECTIONS LXPIRES 7 YEAR FROM DATE ISSUE[ <br />JOB ADDRESS ���`�-� U I LN ISP Ve✓ I ! p� CITY/ZIP �/iN� Q <br />CROSS STREET-��TI?!/! �rJ APN�- 610 - y PARCEL SIZE !� <br />OWNER NAME PViV) ) JA jam¢.(' i� J',I IV iI fA �. �! PHONE <br />OWNER ADDRESS �n%Z �If/ � - n CITY/STATE/ZIPp40i� <br />CONTRACTOR Vim"' ✓`r 1144 S -e /AlG PHONE O9c <br />CONTRACTOR ADDRESS �/S6h �.ti CITY/STATE/ZIP <br />LICENSE 11)�-42 ❑ ❑C-36 OTHER NUMBER / /Q ll'— EXPIRATION DATE <br />WATER TABLE DEPTH: 2.O - G% U ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT #-. LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION CJ R PAIR/ADDITION I i ENGINEER DESIGNED/ALTERNATIVE <br />❑ REPLACEMENT I I OUT -OF -SERVICE SEPTIC SYSTEM L 1 DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 _ NUMBER OF EMPLOYEES: <br />SEPTIC TANK TYPE/MFG CAPACITY Ia00 gal # OF COMPARTMENTS 2 <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ?0 ft FOUNDATION 3S ft PROPERTY LINE OHO ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />1 <br />LEACH LINES <br />❑ LEACHING CHAMBERS # OF LINES <br />c�2 <br />LENGTH OF LINES 7-5 _ <br />ft <br />Permit/ <br />Invoice # <br />Permit ID# <br />Code <br />3S <br />t7O <br />Cash <br />Remitted <br />DISTANCE TO NEAREST <br />WELL ft l FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />FILTER BED, <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />' <br />WELL ft FOUNDATION <br />ft PROPERTY LINE <br />, <br />ft <br />SUMPS <br />WIDTH ori <br />ft LENGTH ` Z/ <br />ft <br />DEPTH /0 <br />ft <br />DISTANCE TO NEAREST <br />WELL'k ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL it FOUNDATION <br />ft PROPERTY LINE <br />ft <br />SEEPAGE PITS <br />NUMBER ice/ <br />WIDTH -1w <br />It <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION <br />ft PROPERTY LINE 49EW <br />ft <br />I HEREBY CERTIFY THAT LHAVE 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE 1���,Gr DATE <br />Application Accept) <br />Final Inspection By <br />Character of Soil to <br />COMMENTS .t <br />_ I n p I /- <br />e EPARTMENT!ISE O LV <br />Date12 Area Employee ID# <br />Date ❑ SPECIAL RMIT -Approved by <br />of 3 Ft: __ Plt/Sump Soil,Character: �ty1A <br />'ti arsP�/!rnYl <br />PE <br />SC <br />Received <br />Check#/ <br />Amount <br />Date <br />Permit/ <br />Invoice # <br />Permit ID# <br />Code <br />INFO <br />By <br />Cash <br />Remitted <br />Service Request # <br />2 2,317L <br />42-01 <br />5/5/17 <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />