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'1'.? 7 2NVIRONMENTAL ONSITE WASTEWATER TREA-rMENT SYSTEM PERMIT <br />ZAN 5� UIN COUNHEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS OL! i <br />CROSS STREET <br />OWNER NAME 14 - <br />OWNER ADDRESS Cs C, M <br />APN 0 c) -) 3 ) j,) 3 2 ' PARCEL SIZE -?.)6 <br />_CITY/STATE/ZIP h �q <br />CONTRACTOR / I , PHONE c� /_�,Sy�'7 <br />CONTRACTOR 1ADDRESS 3 �i,� �'• `, CITY/STATE/ZIP . � / 9d,% <br />LICENSE F1J� 42 [14 C-36 OTHER NUMBER ���EXPIRATION DATE <br />_ PHONE <br />WATER TABLE DEPTH: I " ft GEOGRAPHICAL INFORMATION <br />❑ PERC TEST # BUILDING PERMIT # <br />Coordinates X Y <br />LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM 1 DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG t / -" t <br />❑ GREASE TRAP TYPE/MFG <br />DISTANCE TO NEAREST: WELL %.SO _ _ ft <br />❑ LIFT STATION SIZE —TYPE OF PUMP _ _. _ _ <br />CAPACITY _ gal # OF COMPARTMENTS <br />CAPACITY gal # OF COMPARTMENTS <br />i <br />FOUNDATION ft PROPERTY LINE r40c� j ft <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES I LEACHING CHAMBERS <br /># OF LINES _� LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION �7,D _ ft PROPERTY LINE ft <br />❑ FILTER BED WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL it <br />FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS WIDTH it LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL it <br />FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH _ ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL it <br />FOUNDATION ft PROPERTY LINE ft <br />SEEPAGE PITS NUMBER T WIDTH" <br />ft DEPTH a5� ft <br />ft <br />DISTANCE TO NEAREST WELL' <br />FOUNDATION 30 ft PROPERTY LINE IOO 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED <br />FOR INSPECTIONS - PLEASE CALL 209 <br />SIGNED <br />`953-�7/697� �y <br />TITLE ___ DATE / '-" T , V <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to De <br />COMMENTS C <br />v DEPARTMENT USE ONLY <br />Date I- y -rI Area !41 Employee ID �)'r <br />Date J ' ❑ SPECIAL PERMIT - Approved I <br />PiUSump Soil Character: <br />rC; 01 QP 6s. IA,. <br />"r.,l y U 4 2018 <br />JOAQUIN Cn�JN? r <br />M11pp-, <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />heck <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Re uest # <br />Invoice # SENT <br />�. S <br />as <br />x";.2353 <br />SS) <br />w <br />S?� <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />