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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />I1qUN-h1t1-UfVUACLLJt ^I-LHIVII I L ALL Zuyl Vt)3-/b&1 <br />JOB HDDRESS '/ i - Cl )t <br />tXPIRES 1 YEAR FROM DATE ISSUE( <br />CROSS STREET �k(J IT 9w) APN OS�; --&20��PARCEL SIZE "aJ <br />OWNER NAME IV' 4 Z��---- y� ry/ PHHOON 4" AfQZ-4 <br />;?3 <br />rad <br />OWNER ADDRESS evtYLJ �� CITY/STATE/ZIP OV- e- `O� U <br />CONTRACTOR �� /),Q �e, 6— (` �tA .� _ _ PHONE(c` & <br />CONTRACTOR ADDRESS 12 �( h1stti-A� CITY/STATE/ZIP <br />LICENSE I I C-42 L OC -36 OTHER (21"4, / NUMBER EXPIRATION DATE��%^�� <br />WATER TABLE DEPTH:(' O - of ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # BUILDING PERMIT # `OZ LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE (COMMERCIAL L1 OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTICTANK <br />TYPE/MFG <br />CAPACITY SyC)QO <br />gal # OF COMPARTMENTS <br />tf GR ASE RAP <br />n - / <br />TYPE/MFG S�/V <br />CAPACITY 1. � 0 <br />gal # OF COMPARTMENTS <br />0>l��ati� <br />DISTANCE TO NEAREST: WELL <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />` <br />LlPKG TX PLANT [3SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES LEACHING CHAMBERS <br /># OF LINES LENGTH OF LINES <br />1 <br />DISTANCE TO <br />NEAREST <br />WELL <br />hec <br />ft <br />FOUNDATION <br />Permit/ <br />ft PROPERTY LINE ft <br />❑ FILTER BED WIDTH <br />Code <br />ft <br />LENGTH _ <br />ash <br />Remitted <br />ft <br />DEPTH ft <br />DISTANCE TO <br />NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />El MOUNDED WIDTH <br />ft <br />LENGTH <br />ft <br />wxjz IV <br />DEPTH ft <br />DISTANCE TO <br />NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE t <br />❑ SUMPS WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH N n r ft <br />DISTANCE TO <br />NEAREST <br />WELL <br />ft <br />FOUNDATION <br />/„ <br />ft PROPERTY Ld�� ZU/ /j� ft <br />❑ DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />ft <br />nFPTH . 'EFw QVfN Cn.._ ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 9`TyOF�NTAIYryft <br />❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH MENT ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 />MINIMUMaf HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED �• �Sv� —.%�— TITLE 0),�DATE <br />EPARTMEUTOSEVNLY <br />Application Accepted B Z11 DateWIVII Area Employee ID# <br />Final Inspection By Date �D It_ L7 SPE IAL PERMIT -Approved by <br />Character of Soil to EvPth Ft: 6F _ Pit/Sump Soil Character: <br />CMMENTSAn <br />ta0, <br />PE <br />SC <br />Received <br />hec <br />Amount <br />Permit/ <br />Code <br />INFO <br />B <br />ash <br />Remitted <br />Date <br />Service Request # <br />Invoice # <br />Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />