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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOACIft COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NDN-REFUNDA L P R IT L 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS < CITY/ZI v <br />— /1r- m <br />CROSS STREE APN- W6 G <br />�_� PARCEL SIZE v ' L] v <br />v <br />609 <br />317 <br />z <br />OWNER NAMOU* _ I"qAAAd — PHONnE i <br />OWNER ADDRESS CITY/STATE/ZIP ,/ 1 <br />CONTRACTOR D ,A ' DAafUsw •' v HONE 46-6--()-,6 <br />CONTRACTOR ADDRESS Lamil <br />ITY/STATE2IP <br />LICENSE V IC -42 1-1.-iC-36 OTHER _ NUMBER O S 1 , EXPIRATION DATE v <br />WATER TABLE DEPTH: <br />ft GEOGRAPHICAL INFORMATION: Coordinates X _ <br />Y <br />❑ PERC TEST # <br /># OF LINES LENGTH OF LINES ft <br />Invoice # <br />BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />J NEW INSTALLATION <br />REPAIR/ADDITION <br />ENGINEER DESIGNED /A ERNATIV <br />FILTER BED <br />REPLACEMENT I <br />OUT -OF -SERVICE SEPTIC -SYSTEM <br />DESTRUCTION G <br />INSTALLATION WILL SERVE: RESIDENCE <br />LI COMMERCIAL ❑ <br />OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />(� SEPTIC TANK <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST <br />ft <br />It <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />J4 <br />LEACH LINES <br />LEACHING CHAMBERS <br />Amount <br /># OF LINES LENGTH OF LINES ft <br />Invoice # <br />Permit ID# <br />DISTANCE TO NEAREST <br />WELL 100 <br />ft <br />FOUNDATION ft PROPERTY LINE It <br />❑ <br />FILTER BED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />'57-Ly<j 1 <br />DISTANCE TO NEAREST <br />WELL <br />_ ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft LENGTH <br />It DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />It <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE To NEAREST <br />WELL <br />_ ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />It <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />NUMBER 2— <br />W <br />tit DEPTH ft <br />DISTANCE TO NEAREST <br />WELL r <br />ft <br />FOUNDATION It 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 />Application Accepted <br />Final Inspection By_ <br />Character of Soil to D <br />Employee ID# <br />MIT - Approved by <br />PE <br />SC Received <br />Check#/ <br />Amount <br />PermiU <br />Date <br />Invoice # <br />Permit ID# <br />Code <br />INFO B <br />Cash <br />Remitted <br />ce a est # <br />Iq <br />'57-Ly<j 1 <br />lull wly RUK <br />42-01 <br />5/5/17 <br />OCT 16 2017 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />