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'7 ','& b --7----4- <br />S `f <br />1. ONSITE WAST WATER TREATMENT SYSTEM PERMIT <br />SAN Jol'.IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-76.97 FOR L SPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />7 /a /. . %-7 'ter-_ ✓1 r n --I i" --. . <br />JOB ADDRESS ---' <br />CROSS STREET �� <br />OWNER NAME VAMP <br />OWNER ADDRESS <br />CONTRACTOR <br />(�/ h <br />V 0 <br />1 C:ITY/LIP_��/p�e%/ <br />g v LI 0 r PARCEL SIZE 1��A� Ll <br />PHONE;� <br />CITY/STATE/ZIP w\ n �J q 5, 3 b <br />PHONE <br />GQi � <br />�f�J r[L-' <br />_. APN d <br />���I �j l / <br />�MP <br />i 1` �' <br />CA �� r <br />�J <br />!/ <br />CONTRACTOR ADDRESSCITY/STATE/ZIP <br />ft LENGTH ft DEPTH <br />&_O <br />DISTANCE TO NEAREST <br />LICENSE ACC -42 <br />❑ JC -36 OTHER <br />NUMBER Jg--;9 <br />_7EXPIRATION DATE <br />WATER TABLE DEPTH: �" (/ / ft GEOGRAPHICAL INFORMATION: <br />Ll PERC TEST # BUILDING PERMIT # - <br />TYPE OF WC RK:NEW INSTALLATION J REPAIR/ADC <br />Coordinates X Y <br />LAND USE APPLICATION # <br />)N ENGINEER DESK <br />❑ REPLACEMENT LI OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION _ <br />TERNATIVE <br />INSTALLATION WILL SERVE: _;d -RESIDENCE ❑ COMMERCIAL LI OTHER. <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 2� NUMBER OF EMPLOYEES: <br />�ae�., henenrry / % //f/ nil 8��(`nnnon oTnn�nrTc L/ <br />)yam v r . I <br />- <br />GREASE TRAP TYPE/MFG <br />DISTANCE TO NEAREST: WELL "0 <br />/4 <br />❑ LIFT STATION SIZE TYPE OF PUMP _ <br />CAPACITY gal # OF COMPARTMENTS <br />ft FOUNDATION ft PROPERTY LINE—' ft <br />_ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />E LEACH LINES ❑ LEACHING CHAMBERS # OF LINES ��- LENGTH OF LINES ��r� / _ <br />ft <br />f <br />DISTANCE TO NEAREST <br />is <br />WELL /-,I It FOUNDATION 7�ft PROPERTY LINE_ <br />ft <br />❑ FILTER BED WIDTH _ <br />ft LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION _ ft PROPERTYLINE <br />ft <br />❑ MOUNDED WIDTH <br />ft LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL _ ft FOUNDATION It PROPERTY LINE <br />ft <br />❑ SUMPS WIDTH <br />ft LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft FOUN ATION ft PROPERTY LIN? <br />ft <br />SEEPAGE PITS NUMBER �� <br />_ _ WIDTH * �_ ft DEPTH of LS , <br />ft <br />DISTANCE TO NEAREST <br />WELLZA, It FOUNDATION ft PROPERTY LINE i' <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 OPDINANCES, 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 />SIGNED <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to Dep{i <br />COMMENTS <br />Ll r Ljrf IIVOI-CL, I (VIVO - t-LCAC)C UALL IGVy1 yJJ-/0.7/ <br />TITLE G� DATE <br />DEPARTMENT USE ONLY P' / <br />Date 1 2- SAS Area -I Employee ID# ilL/ <br />Date_ 6 ! ❑ SPECIAL PERMIT - Approved by <br />of t: Pit/Sump Soil Character: <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />T <br />