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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 />IVON-HEFUNDABLE PERMIT// GALL ZUy JbJ-/bF// FOR INSPECTIONS tXPll <br />JOB ADDRESS o��' l0 7 I_ ,' I it J lQ CITY/ZIP <br />� <br />CROSS STREET ✓�C/ APN 2 2-L V )-?2- <br />OWNER <br />3Z - <br />OWNER NAME � C%C,. / 20xx / PHONE <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />PARCEL SIZE / 61 <br />CONTRACTOR OA �v- &F ,7T��e o eul Cf� PHONE <br />CONTRACTOR ADDRESS j416 C/ / Q/�"" I/ CITY/STATE/ZIP <br />LICENSE 1 1 C-42 I C-36 OTHER A NUMBER V Y EXPIRATION DATE <br />WATER TABLE DEPTH: `U ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: fR RESIDENCE ❑ COMMERCIAL F1 OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />i2 It <br />7 <br />U <br />❑ <br />❑ <br />Ath- I Il! I ANN, <br />GREASE TRAP <br />LIFT STATION <br />I YI-E/IVIFLi <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />SIZE TYPE OF PUMP <br />ft <br />RAPACITY <br />CAPACITY <br />FOUNDATION <br />❑ PKG TX PLANT <br />❑ <br />gal iF OF UOMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />FILTER BED <br />WIDTH !% ft LENGTH <br />ft <br />DEPTH %��I <br />Y��37 <br />DISTANCE TO NEAREST WELL /0 0 T ft <br />FOUNDATION -S ft PROPERTY LINE <br />ft <br />❑ <br />MOUNDED <br />WIDTH ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />SUMPS <br />WIDTH ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />DISPOSAL PONDS <br />WIDTH ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE _ <br />ft <br />❑ <br />SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft <br />FOUNDATION <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 />WORKERS COMPENSATION LAWS. <br />MINIMUM 24 tWUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED _ ,,,t cr TITLE 7� U� _ DATE "S <br />PARTMENT OS E N <br />Application Accepted By 40 Date Area Employee ID <br />Final Inspection By Date Zd ❑ SPECIAL RMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/S mp Soil Character: <br />COMMENTS�f ' L 91 A4d"yiy, � <br />WQ_ll sc; backs -Mn 4-)_ -I <br />PE <br />Code <br />SC <br />INFO <br />Received Check#/ <br />By Cash <br />Amount Date <br />Re ' ted <br />Permit/ <br />Request # <br />Invoice # <br />Permit ID# <br />I <br />nService <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />