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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 <br />CALL (209) 953-/7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS _ aY CT7 K Y V i L --y L-A %j c CITY/ZIP AcAr py C-,o� <br />CROSS STREETy "(�SJ �`� o' n APN 1905� W PARCEL SIZE <br />G <br />OWNER NAME CL,�� C.J��I.Io''�5� PHONE -74-7, mi <br />OWNER ADDRES`S_' /SCArNt= LN CITY/STATE/ZIP- <br />CONTRACTOR W `5� W ��� .-)AC � �w�" j IN L — PHONE 5�� ��T <br />CONTRACTOR ADDRESS '61 ," v ' XW EI I _CITY/STATE/ZIP Lo cis Zq �Ca <br />LICENSE IJ 'C-42 ❑ DC -36 OTHER A NUMBER 18-6 11 -7 EXPIRATION DATE <br />WATER TABLE DEPTH: iu V ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION #_ <br />TYPE OF WORK: I NEW INSTALLATION REPAIR/ADDITION I I ENGINEER DESII <br />C_ REPLACEMENT I OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION _ <br />D/ALTERNATIVE <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: �A�,V�� NUMBER OF EMPLOYEES: <br />F-1 CCDTIPTAKII! TVDCAACr, (.APACITV ■��(lAI #nFCnMPARTMFNTS <br />❑ GREASE TRAP <br />❑ LIFT STATION <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL -- <br />SIZE TYPE OF PUMP_ <br />CAPACITY ___ gal # OF COMPARTMENTS <br />ft FOUNDATION It PROPERTY LINE ft <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES 1( LEACHING CHAMBERS) N�� /�T� i # OF LINES Z LENGTH OF LINES '4'0 _ ft <br />DISTANCE TO NEAREST WELL it FOUNDATION Sa ft PROPERTY LINE 2J ft <br />❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft <br />❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS WIDTH __ ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />[� SEEPAGE PITS NUMBER 2- WIDTH 3�7ft DEPTH ZS ft <br />DISTANCE TO NEAREST WELL i SJ ft FOUNDATION So' It PROPERTY LINE 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. 1 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 />MINIMUM 24 HOUR ADVANCE_ NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED" TITLE �r t.s 1A b� DATE <br />Application Accepted By <br />Final Inspection By G� <br />Character of Soil to Depth of 3 <br />COMMENTS 17 , <br />PARTMENT USE 01WLY <br />Date Area GLINYT <br />Employee ID#-� <br />Date 6 - ❑ SPECIAL P - Approved b <br />PP Y <br />Pit/Stjmp Soil Character: &7 <br />/.snl / <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Chec <br />ash <br />Amount <br />Remitted <br />PermiU <br />Date Service Request # <br />Invoice # <br />Permit ID# <br />q c� <br />Yf <br />r� <br />C <br />ft` <br />�T <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />