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ONSITE: WASTEWATER TREATMENT SYSTEM PERMIT p`� <br />SAN JOAQUIN COUNTY ENVIRO:'MEN T AL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNR CALL 209 953-7697FORINSPECTION EXPIR S YEAR ROM DAT ISSUED <br />JOB ADDRESS Ir CITY/ZIP <br />'��ROSS STREET <br />, tt QQ 1�� �^ PARCEL SIZE �• <br />APN ��—�..LI <br />OWNER <br />OWNER ADlJRFSS V V V l/ Y <br />CONTRACTOR_D"A 1'' �% <br />CONTRACTOR ADDRESS46�0 W `� <br />LICENSE x C-42 I] C-36 OTHER A <br />whw '_T66 <br />CITY/STATE/ZIP <br />d5I EXPIRATION DATE Lt " S <br />1 r <br />WATER TABLE DEPTH: J ft GEOGRAPHICAL INFORMATION: <br />I ❑ PERC TEST # BUILDING PERMIT # <br />TYPE OF WORK: ❑ NEW INSTALLATION Y REPAIR/ADC <br />Coordinates X Y <br />LAND USE APPLICATION #_ <br />IN ENGINEER DESH <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM IJ DESTRUCTION _ <br />INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYI <br />'QS SEPTIC TANK <br />❑ GREASE TRAP <br />❑ LIFT STATION <br />TYPE/MFG 11 lyLT— <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />SIZE TYPE OF PUMP <br />CAPACITY r1 <br />CAPACITY <br />It FOUNDATION <br />❑ PKG TX PLANT <br />M <br />NED /ALTERNATIVE <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />JW <br />LEACH LINES <br />LEACHING CHAMBERS <br />hec <br />ash <br />Amount i Date <br />Remitted <br /># OF LINES <br />LENGTH OF LINES J <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />()Pyft <br />PROPERTY LINE _ ( O <br />ft <br />❑ <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 />❑ <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 />_ <br />ft PROPERTY LINE <br />ft <br />❑ <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 />❑ <br />DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />It <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />`SEI <br />SEEPAGE PITS <br />NUMBER I <br />� ? WIDTH <br />1 ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATIONOCX) <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 />WOR <br />SIGN <br />DEPARTMENT USE ONLY <br />ADnli :atinn Accept?d By [late f 7i ,� rR f ArF7. "�_ EmPIoveP ID#_K/ &) q_ _ .. <br />nsaection By___._ Date _ ❑ SPECIAL PERMIT -Approved by <br />wIi. <br />cter of Soii to Depth o Ft: _ Pit/Sump Soil Character: <br />iyy'ENTS " Lt/ 1X1r4lz_"-/ <br />__`-- <br />ID blLv, P at--- n 1,1 A& II, A) _) '� <br />PE <br />Code <br />SC <br />IN <br />Received <br />By B <br />hec <br />ash <br />Amount i Date <br />Remitted <br />Permit/ <br />Request <br />Invoice # <br />Permit ID# <br />* !E�w4b <br />/Service <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />