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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - 209) 468-3420 <br />NON-REFUNDABLE PERMIT A CAL 209 953-7697 FOR INSPECTIONS EXPIRE <br />'`S 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS '�-�'I CITY/ZIP K <br />CROSS STREET < j <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />LICENSE 11 C-42 [IEC -36 <br />APN l.N _ r <br />PARCEL SIZE • <br />24 <br />0465 0 'l� j� y`CITY/STATE/ZIP v� � <br />V1 11 5 ' Kr- PHONE /� a <br />V`�' w CITY/STATE21P l) 1 CJ `SLS/� <br />OTHER A NUMBERI_665[t _EXPIRATION DATE I L -1 <br />----------- n <br />40 <br />LEACH LINES 16 LEACHING CHAMBERS �Q L� # OF LINES LENGTH OF LINES <br />1 ! <br />�O <br />ft <br />WATER TABLE DEPTH: <br />v ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />❑ PERC TEST # <br />BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: <br />I NEW INSTALLATION <br />REPAIR/ADDITION <br />11 ENGINEER DESIGNED/ALTERNATIVE <br />It <br />REPLACEMENT <br />Our -OF -SERVICE SEPTIC SYSTEM <br />I I DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE <br />D COMMERCIAL ' <br />D OTHER <br />NUMBER OF LIVING <br />UNITS: <br />NUMBER OF BEDROOMS:( <br />NUMBER OF EMPLOYEES: <br />SEPTIC TANK <br />TYPE/MFG �[" �� t�� <br />;� <br />1"mµ' �N 2PA1zA{;ITY I9ZO <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />WORKERS COMPENSATION LAWS. <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION _ <br />It PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />----------- n <br />40 <br />LEACH LINES 16 LEACHING CHAMBERS �Q L� # OF LINES LENGTH OF LINES <br />ft <br />�O <br />ft <br />DISTANCE TO NEAREST WELL It FOUNDATION n PROPERTY LINE <br />Date <br />❑ FILTER BED WIDTH It LENGTH It DEPTH <br />It <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ MOUNDED WIDTH __ ft LENGTH _ ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL _ ft FOUNDATION ft PROPERTY LINE <br />It <br />SUMPS WIDTH Itl DEPTH <br />H <br />It <br />DISTANCE TO NEAREST WELLLE <br />ft FOUNDATION �I ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH __ It LENGTH _ ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE <br />ft <br />❑ SEEPAGE PITS NUMBER WIDTH_ ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION 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 />r <br />JOAOUiN 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 />Application Accepted By <br />Final Inspection By --- <br />,4 <br />Cigamcter of Soil to Dept <br />to ' <br />COMMENTS / /r,,J <br />H. <br />=—T -i <br />! Employee ID# <br />MIT - Approved by <br />r� <br />a <br />PE <br />SC <br />Received <br />iCheck <br />Amount <br />Date <br />Permit/Code <br />Invoice # <br />Permit ID# <br />INFO <br />B <br />ash <br />emitted <br />Service Request # <br />U <br />�So3 <br />j <br />r <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />