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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT q/ <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 9U -76A7 FOR INSPECTIONS EXPIRES 1 YEA_Q FROM UAT ISSUE[ <br />JOB ADDRESS AW <br />/ CITY/zIIP <br />CROSS STREET �C/�J APN�/'rT�&`rPARCELSIZE <br />OWNER NAME ��/ U � I C(1 PHONE G� 7 <br />OWNER ADDRESS �, 6 �� CITY/STATE/ZIP ��L� i <br />CONTRACTOR �- , O/Z mic '_ _ --PHONE __�_ � T • / <br />CONTRACTOR ADDRESS t� / CITY/STATE/ZIP <br />LICENSE I l !C-42 11 'C-36 OTHERA/L j C�r NUMBERZ�� EXPIRATION DATE 7 Aai'7 <br />WATER TABLE DEPTH: _ ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />Ll PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGqELTERNATLVfi- <br />REPLACEMENEN OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: L RESIDENCE IJ COMMERCIAL OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: _ NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />❑ GREASE TRAP <br />❑ LIFT STATION <br />TYPE/MFG <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />SIZE TYPE OF PUMP <br />ft <br />CAPACITY <br />CAPACITY <br />FOUNDATION <br />❑ PKG TX PLANT <br />❑ <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />ft <br />❑ LEACH LINES <br />❑ LEACHING CHAMBERS <br /># OF LINES <br />�Z <br />LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SUMPS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH _ __ <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH. _ <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <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 />Application Accepted B <br />Final Inspection By <br />Character of Soil to Depth of 3 Ft: <br />COMMENTS <br />d PARTMENT 11S E10 N L Y <br />Date Area Employee 0#0141& <br />DateVy lb L)SPE IAL PERMIT - Approved by <br />Pit/SU np Soil Character: <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 Re uest # <br />Invoice # <br />Permit ID# <br />s 3 <br />�Z <br />s,e cam- r <br />42-01 <br />5/5/17 <br />t <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />#A- <br />