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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-HEFUND,SL R IT <br />JOB ADDRESS <br />CALL <br />CROSS STREET rAF-1 L ` "imt !'I <br />OWNER NAIA E Al r <br />OWNER ADDRESS , •� <br />CONTRACTOR <br />CONTRACTOR ADDRESS 74/ox"In W <br />LICENSE C-42 I II C-36 OTHER A NUMBER <br />WATER TABLE DEPTH: <br />FOR INSPECTIOIVS— EXPIRES <br />CITY/ZIP A I ls"" <br />w PARCEL SIZE I ID <br />PHONEt 47 <br />1�/ 4_"%06 <br />"PHONEzVo <br />s <br />CITY/STATE/ZIP <br />EXPIRATION DATE <br />ft GEOGRAPHICAL INFORMATION: Coordinates X <br />01 <br />11 <br />PERC TEST # <br />Received <br />lay <br />Chec <br />Cash <br />BUILDING PERMIT # <br />LAND USE APPLICATION # <br />LENGTH OF LINES <br />TYPE OF WORK: <br />NEW INSTALLATION <br />REPAIR/ADDITION <br />ENGINEER DESIGNED/ALTERNATIVE <br />ft <br />REPLACEMENT <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE <br />❑ COMMERCIAL ❑ <br />OTHER <br />ft <br />LENGTH <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />ft <br />DEPTH <br />SEPTICTANK <br />TYPE/MFG �! <br />_ CAPACITY Q 0 <br />gal #OFCOMPARTMENTS <br />❑ <br />GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />ft <br />❑ MOUNDED <br />DISTANCE TO NEAREST: WELL <br />i <br />ft FOUNDATION 1 <br />ft PROPERTY LINE ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />1 LEACHING CHAMBERS <br />Received <br />lay <br />Chec <br />Cash <br /># OF LINES <br />Date <br />LENGTH OF LINES <br />ft <br />Permit ID# <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SUMPS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />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 />FOR <br />DATE <br />' � I 1 1 i 1 ! 1 II 1 1 I I I I' 'II �I 'I f 'I i I 1 ! I ! 1 I �,-• <br />ARTMENT SE L Y PGl ^ / „�,,, • <br />Application Accepted ByDate Area <br />Final Inspection By Date 11SPECIAL PERMIT - App ved b <br />Character of Soil to De of 3 t PIUSump Soil Character: uAY n <br />COMMENTS to Ca--f-itPA 4 S G � � <br />TY <br />411 1/1i I w ONNIENTAL <br />HfrpLTtl DE <br />PE <br />Code <br />Sc <br />INFO <br />Received <br />lay <br />Chec <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />c7 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />