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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 />IVUN-PILFUNDABLE PERMIT <br />G 9 <br />ALL bl9 53-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR F5PM DATE ISSUE <br />JOB ADDRESS ik-7 <br />r w <br />CITY/ZIP <br />C66 <br />CROSS STREET <br />0 <br />APN 2Y, 0 yl)' ©� <br />PARCEL SIZE 20 qc t <br />OWNER NAME .`A <br />, n ores 1 <br />PHONE)_C—Q1-?3K <br />OWNER ADDRESS <br />/.3 Jo �J �� P' vALAI, <br />_ CITY/STATE/ZIP <br />�[ <br />CONTRACTOR <br />W n C�� <br />_ PHONE _ <br />S <br />! i J '73 <br />CONTRACTOR ADDRESS <br />LICENSE I C-42 ❑ C-36 OTHER <br />CITY/STATE/ZIP <br />NUMBER EXPIRATION <br />WATER TABLE DEPTH: L ft GEOGRAPHICAL INFORMATION: <br />PERC TEST # BUILDING PERMIT # <br />Coordinates X Y <br />LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED <br />T5RNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM < DESTRUCTION -10 A I< <br />INSTALLATION WILL SERVE: ❑ RESIDENCE 1_I COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTICTANK <br />❑ GREASE TRAP <br />❑ LIFT STATION <br />TYPE/MFG <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />SIZE TYPE OF PUMP <br />CAPACITY <br />CAPACITY <br />ft FOUNDATION _ <br />❑ PKG TX PLANT <br />7 <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES LEACHING CHAMBERS # OF LINES <br />LENGTH OF LINES <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />❑ FILTER BED WIDTH ft LENGTH <br />ft DEPTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />❑ MOUNDED WIDTH ft LENGTH <br />ft DEPTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />❑ SUMPS WIDTH ft LENGTH <br />ft DEPTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />❑ SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />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 />Y!Aftag4 Wye&VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-769,7,Q <br />SIGNED TITLE 01vn-r <br />DATE 0,3/C_'Mk/ <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />ft <br />:)EFAR'MENT USE ONLY l n A A 1 <br />Application Accepted y Date 3 �% — � ,� Area H G� Employee ID# m e d <br />Final Inspection By Q Date Z� _1 ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS (Je M v () hay+ e <br />PE <br />Code <br />SC <br />INFO <br />Received <br />By <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />Ll �'a I <br />() 7S <br />3 <br />I <br />i <br />' " .i � "C\' <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />n <br />