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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-REFUNDABLE PERMIT GALL 209 953-7697 FOR INSPECTIONS tXPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS 78�� r ��r��Y 1i�t�e J C[TyjzIP ... �j <br />CROSS STREET � zsa 7 APN ©b! —©k- 012 PARCEL SIZE <br />OWNER NAME JFJ!O C f�lJ.eSi PHONE (1-0) 155 r GUL4 <br />OWNER ADDRESS CITY/STATE/ZIP <br />CONTRACTOR /�.�..r f.�/�� Y1i�cr PHONE <br />CONTRACTOR ADDRESS y/��jlo !iJ'SLftJ T%C CITY/STATE/ZIP <br />LICENSE Ejkt-42 [1, C-36 OTHER <br />NUMBER l`S�S EXPIRATION DATE 0�17%,11Ll <br />WATER TABLE DEPTH: / Z% ft GEOGRAPHICAL INFORMATION: <br />❑ PERC TEST # BUILDING PERMIT # <br />TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADC <br />REPLACEMENT LI OUT -OF -SERVICE SEPTIC SYSTEM i DESTRUCTION <br />Coordinates X Y <br />LAND USE APPLICATION # <br />D/ALTERNATIVE <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL 1.1 OTHER <br />NUMBER OF LIVING UNITS: ! NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />❑ GREASE TRAP <br />❑ LIFT STATION <br />TYPE/MFGC/S�►K CAPACITY <br />TYPE/MFG CAPACITY <br />DISTANCE TO NEAREST: WELL ft FOUNDATION <br />SIZE TYPE OF PUMP ❑ PKG TX PLANT <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES <br />❑ LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES yr� ft <br />- <br />DISTANCE TO NEAREST <br />WELL %Gb ft <br />FOUNDATION 25" ft PROPERTY LINE i0 ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />SUMPS (�) <br />WIDTH '%i <br />ft LENGTH <br />L ft <br />DEPTH 8 ft <br />DISTANCE TO NEAREST <br />�I <br />WELL Ij Q t7 ot ft <br />1 -4 <br />FOUNDATION I0 <br />ft PROPERTY LINE 5. 'f ft <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />�— SEEPAGE PITS <br />NUMBER <br />WieT�I <br />^ r ft <br />DISTANCE TO NEAREST <br />WELL <br />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 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 />SIGNED <br />Application Acce <br />Final Inspection <br />Character of Soil <br />COMMENTS <br />4aw3 'f; <br />TITLE 4lVl;k � DATE <br />DEPARTMENT E LY <br />A '�*' q�Date Area Employee!D# <br />Date _ 11 SPECIAL PERMIT -LAPP oved by <br />of 3 Ft: 42 PIUSump Soil Character: <br />PE <br />SC <br />INFO <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/Code <br />Service Request # <br />Invoice # <br />Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5!17 <br />