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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAO'SIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL (209)953-7697 FOR INSPECTIONS LXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS /.gyp (/7 nz ��_�1/ CITYIZIP�:. i IJ4FIez Z > 4z <br />CROSS STREET %� f��L APN� 4 PARCEL SIZE - <br />OWNER NAME v l�t� �W` v PHONE 7[/2��,� <br />OWNER ADDRESS L / �ritlLfC�('� _ CITY/STATE/ZIP7� q w <br />CONTRACTOR n I rv�1 PHONE <br />CONTRACTOR ADDRESS (� _ —CITY/STATE/ZIP G <br />LICENSE 1C C-42 ❑ C-36 OTHER NUMBER _AvEXPIRATION DATE_ <br />WATER TABLE DEPTH: bO - !10 ft GEOGRAPHICAL INFORMATION: <br />❑ PERC TEST #BUILDING PERMIT # <br />TYPE OF WORK: ] NEW INSTALLATION REPAIR/ADE <br />C REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />Coordinates X Y <br />LAND USE APPLICATION #_ <br />INSTALLATION WILL SERVE: 404 RESIDENCE LI COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: / NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />❑ LIFT STATION SIZE TYPE OF PUMP <br />TERNATIVE <br />CAPACITY gal # OF COMPARTMENTS _ <br />CAPACITY gal # OF COMPARTMENTS <br />it FOUNDATION _ It PROPERTY LINE ft <br />. ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />, <br />SC <br />INFO <br />LEACH LINESV LEACHING CHAMBERS # OF LINES LENGTH OF LINES <br />ft <br />/DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ FILTER BED WIDTH it LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE <br />ft <br />❑ MOUNDED WIDTH ft LENGTH it DEPTH <br />ft <br />DISTANCE TO NEAREST WELL itFOUNDATION ft PROPERTY LINE <br />ft <br />rL <br />SUMPS WIDTH ft LENGTH ! ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE <br />_ <br />ElDISPOSAL PONDS WIDTH _ ft LENGTH ft DEPTH ECFn�.4 <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />tt <br />❑ SEEPAGE PITS NUMBER WIDTH it DEPTH UEC 14 2m71t <br />DISTANCE TO NEAREST WELL _ ft FOUNDATION it PROPERTY LIN&ire. _. _ <br />ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCO1415AMXD����/�i4 <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LI �$VT <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />UIRED FOR INSPECTIONS - <br />SIGNED�� ��( __ TITLE DATE,�� <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to De of <br />COMMENTS 4 - <br />Date <br />Date <br />1S PLY <br />Area Employee ID# <br />❑ SPE IAL PERMIT - Approved by <br />Pit/Sump Soil Character: <br />PE <br />SC <br />INFO <br />Received Check# <br />as <br />Amount <br />Remitted <br />Permit/Code <br />Date Service Request # <br />Invoice # <br />Permit ID# <br />g <br />cS"R0707E'I+ 1 - <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />