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_ .ams <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P /! <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NQN-R FUND/lJ�LE PERMIT I . CALL (2M A3-7697 FOR INSPECTIONS - EXPIRES 1 YEAR FROM DATE ISSUED <br />WATER TABLE DEPTH: <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION tNGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT I OUT -OF -SERVICE SEPTIC SYSTEM I DESTRUCTION <br />INSTALLATION WILL SERVE: % RESIDENCE ❑ COMME CIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS:z` BER OF EMPLOYEES: <br />SEPTIC TANK <br />TYPE/MFG Wil._ <br />CAPACITY _ O <br />gal # OF COMPARTMENTS 2— <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />it FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE ___ TYPE OF PUMP--- <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES <br />LEACHING CHAMBERS 1::�IW LA _ _ # OF LINES� <br />Checkgl,.J Amount <br />ash Remitted <br />LENGTH OF LINES <br />y ft <br />Invoice # <br />Per 110 <br />11 <br />^^ <br />69 <br />,'16 <br />5 790 55 <br />DISTANCE TO NEAREST WELLft <br />FOUNDATION <br />PROPERTY LINE <br />ft <br />❑ <br />FILTER BED <br />WIDTH __ It LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION <br />it PROPERTY LINE <br />It <br />❑ <br />MOUNDED <br />WIDTH ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION <br />ft PROPERTY LINE <br />ft <br />SUMPS <br />n <br />WIDTH L It LE GTH <br />� <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL �)4 <br />ft FOUNDATION `/'vu, <br />ft PROPERTY LINE <br />�1 ft <br />❑ <br />DISPOSAL PONDS WIDTH ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft 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 FOUNDATION <br />ft PROPERTY LINE <br />It <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 />WOR <br />SIGN <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to De44 <br />COMMENTS <br />--- 1 .9*ROHM bOU)V rV <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Checkgl,.J Amount <br />ash Remitted <br />Date <br />Permit <br />Service Request # <br />Invoice # <br />Per 110 <br />69 <br />,'16 <br />5 790 55 <br />42-01 ON�ITE WASTEWATE RTMNT SYSTEM PERMIT <br />5/5/17 <br />