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ONSITE WASTEWATER ._a"l F.`.fkTMENT SYSTEM PERMIT Q " <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT GALL (2U,51).953-15,91 FOR INSPECTIONS tXPIRE5 1 TEAR FHOM LJAFE 155UEL <br />JOB ADDRESS �� �G"f�T <br />I 7I''yi(t/q/(���I'[Y <br />Oft L7 CITYRIP n I V0rq <br />I( --fly I _L]?L�i bl/ra <br />CROSS STREET <br />OWNER NAME RIMN <br />TOAt> <br />APN_ <br />PARCEL SIZE <br />PHON <br />U Iw_ INObL�� <br />`�" _ <br />OWNER ADDRESS <br />fes# Ate' `c4,4 Av_ <br />CITY/STATE/ZIP �P <br />�)��/r� <br />CONTRACTOR 7D/µ PHONE 61 <br />� r R���j <br />�.:3A- L'7L�1� <br />j <br />� <br />C �,��� <br />�` C� <br />CONTRACTOR ADDRESS I _:,n+ )Acx✓oN A -a- �J1W 6-CITY/STATE/ZIP <br />LICENSE ❑ C-42 ❑ IC -36 OTHERNUMBER 1 / EXPIRATION DATE __ <br />{ �! ✓ I / P <br />WATER TABLE DEPTH: _ ft GEOGRAPHICAL INFORMATION: <br />❑ PERC TEST # BUILDING PERMIT # <br />TYPE OF WORK: NEW INSTALLATION X REPAIR/ADE <br />Coordinates X Y <br />_ LAND USE APPLICATION #_ <br />>N ENGINEER DESA <br />REPLACEMENT 1! OUT -OF -SERVICE SEPTIC SYSTEM I DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE * COMMERCIAL ❑ OTHER LL <br />NUMBER OF LIVING UNITS: ii �0 NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />L'NL✓� <br />SEPTICTANK TYPE/MFG V ` <br />❑ GREASE TRAP TYPE/MFG <br />D /ALTERNATIVE <br />-/ DISTANCE TP NEAREST: WELL <br />i W LIFT STATION SIZE (d b Ac TYPE OF <br />•J APACITY IT- gal # OF COMPARTMENTS <br />CAPACITY gal # OF COMPARTMENTS <br />ft FOUNDATION _ ft PROPERTY LINE ft <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />• � <br />JLEACH LINES I LEACHING CHAMBERS <br />i # OF LINES 1 d d <br />Ib�, LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION r� ft PROPERTY LINE <br />ft <br />❑ FILTER BED WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE _ <br />ft <br />❑ MOUNDED WIDTH ft LENGTH <br />ft DEPTH <br />ft <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 />ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH _ _ ft LENGTH — <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />_ ft FOUNDATION _ _ ft PROPERTY LINE <br />ft <br />❑ SEEPAGE PITS NUMBER __ WIDTH <br />_ __ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />_ ft FOUNDATION _ _.. ft PROPERTY LINE <br />ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION <br />AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES <br />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 COMPENSA=LON LAWS. <br />SIGNED <br />Application Accepted <br />Final Inspection Bye <br />Character of Soil to D <br />COMMENTS <br />DEPARTMENT USg ONLY <br />Date Area Employee 1D# <br />Date ❑ SP CIAL PERMIT - Approved by <br />of 3 Ft: 64a-141 Xi I., Pit/Sump Soil Characterr:�/ c^ <br />1LLnr n .. '�- 8 /1w .L1 A D_1. /L%I Ulla -Cr 1 <br />I <br />[i <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />L Cq!Sko <br />ash <br />AmouU <br />Remitted <br />Date <br />zwl Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />9sq <br />1 <br />JLV-fb <br />ky%* t cfb <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />