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1p ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SSN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON -REFUND LE PE MI1V , CALL 20 953-7697 FOR INSPEC TIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS CITY/ZIP <br />CROSS STREETVLZ� Q F 55'0QGn�- APN /� ' - � a 4760 - PARCEL SIZE <br />OWNER NAME.W�.1aL �"� 1 � 1 1 PHONE 4st� <br />-3 <br />OWNER ADDRESS + CITY/STATE/ZIP <br />y • <br />t` v VI o-7 <br />CONTRACTOR + 1Amj PHONE <br />CONTRACTOR ADDRESS 9 ` CITY/STATE/ZIP' <br />LICENSE C-42 I I C-36 OTHER NUMBER f7� 11 EXPIRATION DATE k <br />WATER TABLE DEPTH: 4NU --- f%U ft GEOGRAPHICAL INFORMATION <br />LJ PERC TEST # BUILDING PERMIT # <br />TYPE OF WORK: NEW INSTALLATION if REPAIR/ADI <br />Coordinates X Y <br />LAND USE APPLICATION # <br />REPLACEMENT I OUT -OF -SERVICE SEPTIC SYSTEM <br />DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <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 />TERNATIVE <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES <br />I LEACHING CHAMBERS <br />eck#/ Amount <br />s Remitted <br />Date <br /># OF LINES <br />LENGTH OF LINES <br />ft <br />t� <br />DISTANCE TO NEAREST <br />WELL <br />59 21 <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />FILTER BED <br />WIDTH <br />It <br />LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAR�'J�T <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LI <br />ft <br />1110 <br />SUMPS <br />WIDTH G- <br />ft <br />LEN, TH <br />ft DEP <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />� <br />ft <br />FOUNDATION ft PROPERTY <br />ft <br />❑ <br />DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY MAY <br />ft <br />❑ <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />_ <br />ft <br />FOUNDATION <br />ft PROPERT)gUINCOU�»� ft <br />an. --. <br />-n UEP�qp� -•— <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDMWIA NT 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 />WORKE <br />SIGNED <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to De <br />COMMENTS lQa.% <br />Pit/Sump Soil Character: <br />Employee ID#9- 944—Al. <br />- Approved by <br />PE <br />Code <br />SC <br />INFO <br />Received <br />eck#/ Amount <br />s Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />t� <br />59 21 <br />C f� <br />5 - <br />S�e.� Y 2 -fir ; r► s� 2L-t-� c <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />