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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 , CALL (209) 953-7697 F4Q1 SPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 41 -PT 7 -3 *'T F-- 1C.1 i#xr- /C n1. N-/ -CITY/71P <br />CROSS STREET , APN / * V l D 3' PARCEL SIZE <br />OWNER NAME _ PHONE <br />OWNER ADDRESS CITY/STATE/ZIP <br />a �y <br />CONTRACTOR PHONE <br />PHONE�x <br />CONTRACTOR ADDRESS s CITY/STATE/ZIP iQJ�A/%t' ��fy'!t C • <br />LICENSE ❑'nC-42 ❑ _IC -36 OTHER4"Ourgi NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH 'Z2 V _. ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION 1 ENGINEER DESIGNED ALTERNATIVE <br />REPLACEMENT 11 OUT -OF -SERVICE SEPTIC SYSTEM 11 DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL OTHER MA <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />SEPTIC TANK TYPE/MFG ACITY gal # OF COMPARTMENTS_ <br />❑ GREASE TRAP TYPE/MFG A ACITY gal # OF COMPARTMENTS <br />f <br />DISTANCE TO NEAREST: WELL �a© it FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES <br />❑ LEACHING CHAMBERS <br /># OF LINES <br />D e <br />LENGTH OF LINES <br />ft <br />Permit ID# <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />irk <br />ft PROPERTY LINE <br />ft <br />LY <br />FILTER BED <br />WIDTH 20 ft LENGTH <br />40 <br />ft <br />DEPTH k 610 <br />ft <br />�\ <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />MOUNDED <br />WIDTH ft LENGTH <br />3L6 <br />ft <br />DEPTH <br />ft <br />DISTANCE To NEAREST WELL__ <br />ft FOUNDATION <br />/ <br />ft PROPERTY LINE <br />ft <br />Ll <br />SUMPS SUMPS <br />WIDTH 00 r ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />DISPOSAL PONDS WIDTH ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WI I_L <br />ft 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 />SIGNED <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to Depth of 3 Ft: <br />COMMENTS <br />ICE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE �J�eA .-..7 DATE/ % <br />TMEW PSEIONLY <br />Date t- / Area Employee ID# A*"Irp— <br />Date 12166-1 ❑ SPE IAL PERMIT - Approved by <br />Pit/Sump Soil Character: <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Check#/ Amount <br />Cash Remitted <br />D e <br />Permit/ <br />ervi R u st # <br />Invoice # <br />Permit ID# <br />irk <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />02 <br />