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ONSITE WASTEWATER TREA`rMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT . GALL (ZU!)) J53 -1b,91 FOR INSPECTIONS tXNIHES I TtAH I -HUM U/A I t I„UtU <br />JOB ADDRESS S �G % CITY/ZIP <br />CROSS STREET APN ©�1 Q `L.O PARCEL SIZE / <br />OWNER NAME /..1�G PHONE / 'g�1/3" <br />OWNER ADDRESS !<A" t 1r_ 18513 C lwq &d CITY/STATE/ZIP —Lok CA q 5 40 <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />LICENSE ❑ C-42 [ C-36 OTHER <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: _ _ It GEOGRAPHICAL INFORMATION <br />❑ PERC TEST # BUILDING PERMIT # <br />TYPE OF WORK: N NEW INSTALLATION REPAIR/AD <br />nates X Y <br />2 LAND USE APPLICATION # <br />ENGINEER DESIGNED <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: ISI RESIDENCE I I COMMERCIAL OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: �vO NUMBER OF EMPLOYEES: <br />TERNATIVE <br />0 SEPTIC TANK <br />TYPE/MFG Cay0 Z j? f A-:-___ <br />_ CAPACITY -2-00 _ gal <br /># OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG,,^^ <br />CAPACI VY gal <br /># OF COMPARTMENTS <br />ft <br />DISTANCE TO NEAREST: WELL loo d <br />ft FOUNDATION ft <br />t� <br />PROPERTY LINE J ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP_ <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES ❑ LEACHING CHAMBERS <br /># OF LINES 2. LENGTH OF LINES -1b <br />ft <br />DISTANCE TO NEAREST WELL �� <br />ft FOUNDATION t1D ft PROPERTY LINE L) <br />- <br />ft <br />❑ FILTER BED WIDTH ft LENGTH <br />t DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION ft PROPERTY LINE <br />ft <br />❑ MOUNDED WIDTH _ It LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION _ ft PROPERTY LINE <br />ft <br />�( <br />SUMPS WIDTH : ft LENGTH <br />_ <br />t _2— ___ _____ ft DEPTH 10 <br />ft <br />/ DISTANCE TO NEAREST WELL <br />ft FOUNDATION 1 ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH _ <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION _ It PROPERTY LINE <br />ft <br />NUMBER WIDTH <br />It DEPTH <br />ft <br />DISTANCE TO NEAREST WELLIt <br />_� <br />FOUNDATION It PROPERTY LINE +4LT <br />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 <br />REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS <br />STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMU 24 O R ADV NCE NOTICE REQUIRED FOR INSPECTIO S -PLEASE CALL 209 953V76 <br />SIGNED ^% /. / % t TITLE- �iC JZ Z DATE <br />r <br />NT <br />ED <br />T <br />Application Accepted B <br />Final Inspection By <br />Character of Soil to Depth of 3 Ft: <br />COMMENTS <br />DEPARTMIF NT LS-' %4LY <br />Date - Area Employee ID# <br />Date Z _�Q�CI SPECIAL PERMIJ Ap oved by <br />Pit/Sump Soil Character: G�l 7 <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />q�xll <br />Vb33 <br />l <br />51 S <br />5th <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />