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ONSITE WASTEWATER TFIEATMENT SYSTEM PERMIT /1P/' <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERRMIT CALL 209 953-7697 FOR INSPECTIONS <br />tXPIRES 1 YEAR FROM UATE ISSUE[ <br />JOB ADDRESS L <br />n^I, <br />3�7�� QAN.A�dV� <br />CITY/ZIP <br />0f aZ-? <br />ft PROPERTY LINE_ftA. ft <br />CROSS STREET <br />tj lficN�T� <br />APN QQ <br />PQaCELSIZE <br />❑ SUMPS WIDTH ft LENGTH - <br />ft DEPTH Ii is <br />` t <br />ft PROPERTY LINE ffy <br />OWNER NAME <br />/e <br />�.�\ r� �l���rIv1JCU�.//Y_aTr�ji <br />C� w <br />PHONE��I�%(d �IfJi ""� /7 71.? <br />PITS NUMBER `7 WIDTH 3b �r <br />OWNER ADDRESS <br />Q <br />Ad <br />i <br />T,QI� �l�I�' ITY/STATE/ZIP-Z-0 f <br />.) 1- O <br />CONTRACTOR <br />C OPYg1 <br />__AI C PHONE �I <br />S <br />.�I���Ct]�: <br />CONTRACTOR ADDRESS <br />CITY/STATE/ZIP _ _ <br />A��rA 01",-!g0 <br />A <br />EXPIRATION DATE <br />�U <br />LICENSE ❑' !C-42 <br />❑ IC -36 OTHER <br />NUMBER _0"7 <br />,1f � <br />WATER TABLE DEPTH: I Id Z� ft GEOGRAPHICAL INFORMATION: <br />❑ PERC TEST # BUILDING PERMIT # <br />77P� <br />TYPE OF WORK: NEW INSTALLATION >C REPAIR/ADC <br />Coordinates X Y <br />LAND USE APPLICATION #— <br />)N ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT i i OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: I RESIDENCE ❑ COMMERCIAL u <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: AIOT AYMLe96I <br />❑ SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />❑ LIFT STATION SIZE TYPE OF PUMP <br />CAPACITY <br />ft FOUNDATION <br />❑ PKG TX PLANT <br />❑ OTHER <br />NUMBER OF EMPLOYEES: <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />iv <br />LEACH LINES ❑ LEACHING CHAMBERS # OF LINES LENGTH OF LINES `10 ft <br />T, <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE E3) ft <br />❑ FILTER BED WIDTH _ ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE_ftA. ft <br />❑ MOUNDED WIDTH ft LENGTH <br />ft DEPTH <br />DISTANCE To NEAREST WELL ft FOUNDATION <br />A� <br />ft PROPERTY LINE L�J�1tft� <br />❑ SUMPS WIDTH ft LENGTH - <br />ft DEPTH Ii is <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ffy <br />El DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH ANJO /ffp <br />_ <br />DISTANCE TO NEAREST WELL 16W ft FOUNDATION <br />ft PROPERTY LINER V/RO C- <br />r7 'YSEEPAGE <br />PITS NUMBER `7 WIDTH 3b �r <br />ft DEPTH 2—S ;z_--rfPART�,ILryft <br />DISTANCE TO NEAREST WELL ISO F ft FOUNDATION <br />.��_ ft PROPERTY LINE%i( If <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. <br />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 />MINIMUM 24 HOUR AD NCE OTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 , <br />MreVk[�7 <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to Dept <br />COMMENTS <br />DATE � I l `D_i <br />DEPARTMENT SEY <br />Date Area Employee ID# --,y <br />'t _ Date k ❑ SPECIAL PERMIT - Approved by <br />of 3 Ft: Pit/Sump Soil Character: <br />PE <br />Code <br />SC <br />INFO <br />Received <br />Check#/ <br />Cash <br />Amount <br />Remit ed <br />ate Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />42-01 (5W. . ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 �(J �� I [ <br />