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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT Ev L s,�� - 709z) <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT GALL (ZUYI 953-769/ FOR INSPECTIONS r_XPIHL,i I T`LAAH I -HUM WA It IbbUtL <br />JOB ADDRESS C�ITYfzIIPP <br />CROSS STREET W. ra-D APN ��i• �•--" � PARCEL SIZE p / 2 <br />' 1 y <br />F--=AO/U UN//C/G�� /` L. ///S7/L/G 7- PHONE�� <br />OWNER NAME Al,OWNER ADDRESS <br />��-SO/ A&GAL4A ,w e _ CITY/STATE/ZIP �p� AJ sS36 <br />j� <br />CONTRACTOR V � ' PHONE �C/�( �Z /7/70C/ <br />CONTRACTOR ADDRESS �� ��OiI' ��CITY/STATE/ZIP _ TO�1- rvvv S2� <br />LICENSE 11 C-42 ❑❑C-36 OTHER �NUMBER EXPIRATION DATE_ <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: <br />L PERC TEST # BUILDING PERMIT # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/AD[ <br />Coordinates X Y <br />LAND USE APPLICATION # <br />)N ENGINEER DESIGNEI <br />TERNATIVE <br />REPLACEMENT 11 OUT -OF -SERVICE SEPTIC SYSTEM ?C� DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ 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 />CAPACITY <br />CAPACITY <br />ft FOUNDATION <br />❑ 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 ■ LEACHING CHAMBERS <br />#OFLINES—• <br />Received <br />DISTANCE To NEAREST WELL <br />ft FOUNDATION It PROPERTY LINE <br />It <br />■ FILTER BED WIDTH ft LENGTH- <br />ft DEPTH <br />ft <br />DISTANCE To NEAREST WELL <br />ft FOUNDATION It PROPERTY LINE <br />ft <br />■ MOUNDED <br />Remitted <br />DISTANCE To NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />■ SUMPS WIDTH ft LENGTH <br />ft DEPTH - <br />ft <br />DISTANCE To NEAREST WELL <br />It FOUNDATIONPROPERTY <br />El DISPOSALPONDS WIDTH ft LENGTH <br />ft DEPTH <br />DISTANCE • NEAREST WELL <br />ft FOUNDATIONPROPERTY <br />■ SEEPAGE PITS NUMBER WIDTH <br />It DEPTH <br />ft <br />To NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE <br />ft <br />APPLICATIONDISTANCE <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS <br />•• DONE IN ACCORDANCE <br />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 />WORKERSJOAQUIN <br />• • <br />HOLMaDVANCE NOTICE-BEOVIRED <br />FOR INSPECTIONS - PLEASE CALL (209) <br />SIGNED <br />TITLE DATE <br />■.■■■■...■■■■■■■.■.■■■■■■■.■...■■..■... <br />NOON■■E■■■E■■■■�!�r%s!ii'`n1 <br />NONE <br />['���1_�,1].■EE■■■N■NN■■SEE■ <br />■..........................■■...■_■■■■■■■■■■ <br />• <br />i , <br />•ice <br />• y�riL1,; A W <br />la A �l <br />��, <br />PE <br />SC <br />Received <br />Check#/ <br />Amount <br />Date <br />Permit/Code <br />Invoice # <br />Permit ID# <br />INFO <br />8 <br />Cash <br />Remitted <br />Service Request # <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />