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((ff Joh ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />AN <br />SJt!UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />JOR ADDRFSS S <br />GALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM UATE ISSUED <br />A ✓ e ,- w), , &,J,, ' ITY/ZIP 1,4AAj vELA 9:5;2.s <br />CROSS STREET ` APN °� /`�� 3 9 0 S � �+ PARCEL SIZE 7942- <br />OWNER NAME �.¢ l /`/�NGJ_f�_�(j/�� I Ulm PHONE <br />OWNER ADDRESS�/��/ CITY/STATE21P G (/ <br />C"9NTRACTOR !/ �'� C/, / -/ ALo�E ..4 I✓G . _- _ _ PHONE "7 <br />CONTRACTOR ADDRESS /mob ��' `J Z CITY/STATE/ZIP <br />LICENSE 11C 42 ❑DC -36 OTHER Aj V -'z/ NUMBER _ EXPIRATION DATE <br />WATER TABLE DEPTH: I t� l� _ ft GEOGRAPHICAL INFORMATION: Coordinates X _ _ Y <br />) PERC TEST # [ BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: U NEW INSTALLATION I REPAIR/ADDITION ENGINEER DESK <br />NED/ALTERNATIVE <br />11 REPLACEMENT I I OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION l j0 I • } ui') <br />INSTALLATION WILL SERVE: RESIDENCE LI COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />❑ LIFT STATION SIZE TYPE OF PUMP <br />❑ LEACH LINES ❑ LEACHING CHAMBERS <br />CAPACITY <br />CAPACITY <br />ft FOUNDATION — <br />❑ PKG TX PLANT <br /># OF LINES <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LENGTH OF LINES <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION <br />ft PROPERTY LINE <br />❑ FILTER BED WIDTH <br />ft LENGTH <br />ft DEPTH <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION <br />ft PROPERTY LINE <br />❑ MOUNDED WIDTH <br />ft LENGTH <br />ft DEPTH <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION <br />ft PROPERTY LINE <br />❑ SUMPS WIDTH <br />ft LENGTH <br />ft DEPTH <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION <br />ft PROPERTY LINE <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft DEPTH <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION <br />ft PROPERTY LINE <br />❑ SEEPAGE PITS NUMBER <br />WIDTH___ __ <br />ft DEPTH <br />DISTANCE TO NEAREST <br />WELL ft FOUNDATION <br />ft PROPERTY LINE <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. <br />I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD <br />AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />ADVANCE NOTICE REQUIRED FOR INSPECTIONS - <br />SIGNED /-In. TITLE _- �/9`��y/ZELT� i DATE <br />i ucTr•v�mc�•� � <br />Application Accepted B - Date 2 <br />Final Inspection By Date_L <br />Character of Soil to Depth of 3 Ft: _ <br />CO�MENTS Re ON 0 Ve <br />ey7lOy< at fIc eil Inc, truun <br />The Secr✓n d b n K WCA S n )� Con�', <br />It <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />if, <br />Area� N Employee ID# A <br />❑ SPECIAL PERMIT - Approved by <br />ip Soil Characters: __ <br />ii\ �\I torn n d SPl1 isGK- <br />4er Obrn 4;n, �Gn irn �5 <br />PE <br />42-01 <br />Sc <br />Received CAmount <br />Date <br />Permit/ <br />Invoice # <br />Permit ID# <br />Code <br />INFO <br />By Cash Remitted <br />Service Request # <br />baa 1 <br />015 <br />I L a- <br />0112 5-6- <br />6 <br />42-01 <br />5/5/17 <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />CA <br />