SR0078271 - Laserfiche WebLink

Home Browse Search

ONSITE WASTEWATER TREATMENT SYSTEM PERMIT Q✓ AN JDAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM UATE ISSUE[ JOBADDRESS 3 CITY/ZIP 5 c0"/7, Kfj— CROSS STREET 5 �CI FIS _ _ _ APN 7 3 3 O`er Q lk PARCEL SIZE �'✓ OWNER NAME l O 4 _.. _ � � __ HONE 8 (,5- ' /j 0 ;),;L - OWNER eL-OWNER ADDRESS 1 W � 6- I �� a _ CITY/STATE/ZIP CONTRACTOR /to4,1I I V q //w �wO � L _ .. _ PHONE r;to CONTRACTOR ADDRESS �� b�Say /� _ CITY/STATE/ZIP LICENSE 11'k42 ❑ IC -36 OTHER NUMBER _ SfO�J . EXPIRATION DATE---! o / 9 V IJ u n_ i. ...r .. I- .Ai av v 1 ` PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: 7 NEW INSTALLATION X REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE 1-1 REPLACEMENT I OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: X RESIDENCE I I COMMERCIAL OTHER NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: xSEPTIC TANK TYPE/MFG _6y`IC `i -c _ /�� _ CAPACITY C?000 gal # OF COMPARTMENTS O1- ❑ GREASE TRAP TYPE/MFG _ CAPACITY gal # OF COMPARTMENTS / DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE /0 O ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS Received heck# # OF LINES Date LENGTH OF LINES ft Invoice # DISTANCE TO NEAREST WELL INFO ft FOUNDATION Remitted ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH " _ T_ ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LI Gc IVE n ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 2017 ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH SAFN�ft tuuiyT-Y DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPER Tf�,LyyFVIRO NI'll MENT ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH T ED ARTAA�r ft DiS-AN;.E TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL SIGNED /TITLE�/d N y�f�� - DATE lQ Application Accepted By - Final Inspection By Character of Soil to Depth COMMENTS DEPARTMENT USE ONLY Date - ! Area Employee ID# h� 6 Datell ❑ SPECIAL PERMIT - Approved by 3 Ft: Pit/Sump Soil Character: 1I/- 4A- linh 'Tr,Ir 2 PE SC Received heck# Amount Date Permit/ Invoice # Permit ID# Code INFO B, Remitted Service Request # 11uL J5 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17