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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON -REFUND B PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 Y AR FROM DATE ISSUED <br />JOB ADDRESS VeD CITY/ZIIP�% <br />CROSS STREET, © APN V A� PARCEL SIZE 15 <br />OW14ER NAMYsil-ice- L.1= -- <br />OWNER ADDRESS 'Q , 2 G. <br />CONTRACTOR `�' /� �� <br />CONTRACTOR ADDRESS <br />LICENSE I -x "C-42 ❑ C-36 OTHER <br />dr rS--*VII3 CITY/STATE/ZIP�q�C� <br />y "S V' ` ' C PHONE - / 6 0 <br />Ii <br />L-)I"y, CITY/STATE/ZIP <br />NUMBER V EXPIRATION DATE LL .j 9 <br />WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # .__ LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION Li REPAIR/ADDITION I i ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT L OUT -OF -SERVICE SEPTIC SYSTEM L DESTRUCTION <br />INSTALLATION WILL SERVE: 11f RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: A4-- NUMBER OF EMPLOYEES: <br />;S <br />SEPTIC TANK <br />TYPE/MFG T CAPACITY <br />gal # OF COMPARTMENTS <br />Date Permit/ <br />❑ <br />GREASE TRAP <br />TYPE/MFG CAPACITY <br />INFO <br />gal # OF COMPARTMENTS <br />ash <br />Remitted <br />Service Request #41 <br />6 <br />DISTANCE TO NEAREST: WELL _ It FOUNDATION <br />it PROPERTY LINE L )k—/ <br />ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES <br />Y LEACHING CHAMBERS v 2A # OF LINES <br />LENGTH OF LINES '.1 <br />It <br />DISTANCE NEAREST T ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />TO WELL <br />❑ <br />FILTER BED <br />WIDTH _ ft LENGTH _ _ _._. <br />ft <br />DEPTH <br />It <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />It <br />❑ <br />MOUNDED <br />WIDTH ft LENGTH <br />ft <br />DEPTH <br />It <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />SUMPS <br />WIDTH ft LENGTH _ <br />It <br />DEPTH <br />It <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />DISPOSAL PONDS WIDTH It LENGTH <br />ft <br />DEPTH <br />It <br />DISTANCE TO NEAREST WELL _ _ _ _ ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />SEEPAGE PITS <br />NUMBER WIDTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE qO p <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 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 />"I&INN HO A R OUIRED FOR 10 - RLEASE CALL(209)943 7697r� <br />SIGNED TITLLLUAMW DATE <br />Application Accepted <br />Final Inspection By -7 <br />Character of Soil to D <br />COMMENTS -� <br />ti ":IL <br />DEPARTMENT USE ONLY <br />Date Area Employee ID# <br />Date 2 ❑ SPECIAL PERMIT - Approved by <br />of 3 Ft: Pit/Sump Soil Char cter: <br />J2 C <br />I <br />PE <br />SC <br />ReceivedChec <br />Amount <br />Date Permit/ <br />Invoice # <br />Permit ID# <br />Code <br />INFO <br />B <br />ash <br />Remitted <br />Service Request #41 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />T <br />