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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P r <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />JOB ADDRESS <br />CROSS STRE <br />OWNER NAM <br />LXPIRES 1 YEAR FROM DATE ISSUEI <br />PARCEL SIZE 443.,'- <br />OWNER ADDRESS y� �/ 7 /V p De V r R �_ _ CITY/STATE/ZIP*� CJC1 r7 <br />CONTRACTOR <br />CONTRACTOR /�fIt 'f{I VJ 4(Cl � 'G PHONE FJ`� • q'S"o.�/ <br />�''�+ <br />CONTRACTOR ADDRESS r (Cyl .SD►�I `%�°�' CITY/STATE/ZIP 6dr0/1� 4�I� <br />LICENSE CIRC -42 FILIC-36 OTHER NUMBER �5Lq�LEXPIRATIONDATE -J(i 11 <br />WATER TABLE DEPTH: 3 v ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />1 1 PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: '1 NEW INSTALLATION LI REPAIR/ADDITION I I ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT !j OUT -OF -SERVICE SEPTIC SYSTEM I i 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 />CAPACITY <br />CAPACITY <br />DISTANCE TO NEAREST: WELL fl FOUNDATION <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT <br />gal # OF COMPARTMENTI-)- <br />gal # OF COMPARTMENTS <br />It PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />LEACHING CHAMBERS rO CA4t!#b0fj # OF LINES <br />Received <br />B <br />LENGTH OF LINES <br />DISTANCE <br />Amount <br />Remitted <br />TO NEAREST <br />WELLft <br />FOUNDATION <br />30 <br />ft <br />ft PROPERTY LINE t <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH It <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />It LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />❑ SUMPS <br />WIDTH <br />_ ft LENGTH <br />It <br />DEPTH CF/1�,► <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft <br />DEPTH 8 2W.ft <br />ft <br />ft PROPERTY LINMNJOA,,.._ It <br />DISTANCE TO NEAREST <br />WELL _ <br />FOUNDATION <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH__ <br />ft <br />DEPTH 11C47,;1RO�O�u <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />_ <br />It PROPERTY LINE EpART..-.. _ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT -I FIE 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 />UR A <br />SIGNED <br />Application AcceptedB4th3 <br />Final Inspection By_Character of Soil to D <br />COMMENTS <br />- PLEASE CALL (209) 953-76; <br />e-- DATE 3 '9 <br />'TMENT USE ONLY <br />Date - Area Employee ID# <br />Date ❑ SPECIAL PERMIT - Approve by <br />Pit/Sump Soil Character: <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Check# <br />s <br />Amount <br />Remitted <br />D to <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />T <br />