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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE aPE�RJMIT �J CALL 209 953-7697 FOR INSPECTIONS ` /EXPIRES 1 YEAR FROM <br />nDATE ISSUED <br />JOB ADDRESS 5-q / ki.,,c -h CYi �'L� MflJ CITYRIP DLII ` gSZT v <br />CROSS STREETi�r "ae 1I4 _ APNasw/UOQ-_ PARCEL SIZE <br />OWNER NAME F4�'U (-jc-- t� _ . __ PHONE j <br />OWNER ADDRESS ' q /'t N' ✓ CITY/STATE/ZIP [�xD 1 `.J <br />CONTRACTOR i�.P�'i cf I V.r I S �L PHONE doi—, ^3(%e 9-52) 97 �ry <br />CONTRACTOR ADDRESS +,j��I V' >� Dr• CITY/STATE/ZIP zedl i <br />LICENSE 11 iC-42 ❑CIC -36 OTHER NUMBER /'•' /V EXPIRATION DATE <br />WATER TABLE DEPTH:%lJ C/y It GEOGRAPHICAL INFORMATION: Coordinates X _ _ _ _ _ _ Y <br />❑ PERC TEST # BUILDING PERMIT #17 1 _ AND USE APPLICATION #_ <br />TYPE OF WORK: X NEW INSTALLATION REPAIRIADDITION ENGINEER DESI( <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />NED /ALTERNATIVE <br />INSTALLATION WILL SERVE: RESIDENCE ❑ <br />COMMERCIAL L I OTHER <br />Received <br />B <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS:__-. NUMBER OF EMPLOYEES: <br />Amount <br />emitte <br />SEPTIC TANK TYPE/MFG <br />CAPACITY IStao gal # OF COMPARTMENTS <br />❑ <br />GREASE TRAP TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />aj <br />' <br />/Q & C7 <br />DISTANCE TO NEAREST: WELL /� ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />LIFT STATION SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES F, LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES ft <br />/ <br />J QO <br />DISTANCE TO NEAREST WELL Lft <br />� I <br />FOUNDATION �G ft PROPERTY LINE �+S ft <br />❑ <br />FILTER BED WIDTH _ ft LENGTH _ <br />ft, DEPTH ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION It PROPERTY LINE ft <br />❑ <br />MOUNDED WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SUMPS WIDTH ft LENGTH _ <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH _— ft LENGTH <br />ft DEPTH it <br />DISTANCE TO NEAREST WELL ftFOUNDATION <br />ft PROPERTY LINE It <br />SEEPAGE PITS NUMBER 2WIDTH _ --' <br />ft DEPTH �S ft <br />DISTANCE TO NEAREST WELL tt <br />FOUNDATION 30 ft PROPERTY LINE ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND <br />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 <br />LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to Depth of 3 <br />COMMENTS <br />DATE /9-a% 17 <br />T <br />11- <br />I S N L Y /v/��v/ kJ l Xq <br />Area —�F� Employee ID#�w7ny�l <br />20Z�- CI SPECIAL PERMIT - Approved by <br />Pit/Sump Soil Character: best a� j "&A% <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Chec <br />sh <br />Amount <br />emitte <br />Ds a Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />aj <br />14 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />