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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 />NON -REFUND B F,,ERVII.CALL 09 953-7697FORINSPECTION 5 EXPI S 1 Y R FROM DATE ISSUED <br />JOB ADDRESS ffagsrtbCITY/ZIP <br />CROSS STREET V\)U IU1 n u \ W Q!■ i..Nr ' APN U01 "U 3()' ILU PARCEL SIZE <br />1 f <br />OWNER NAME a PHONE <br />OWNER ADDRE `� CITY/STATE/ZIP <br />%2- <br />CONTRACTORIJA - PHONE ` <br />CONTRACTOR ADDRESS i 1 CITY/STATERIP <br />LICENSE /IC -42• ❑I C-36 OTHER NUMBER C-� ` EXPIRATION DATE kill f <br />WATER TABLE DEPTH: ", r ft GEOGRAPHICAL INFORMATION <br />❑ PERC TEST # BUILDING PERMIT # <br />TYPE OF WORK: NEW INSTALLATION X REPAIR/ADI <br />Coordinates X Y <br />LAND USE APPLICATION #_ <br />IN ENGINEER DESH <br />REPLACEMENT I OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: [ RESIDENCE ❑ COMMERCIAL Ll 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 />V <br />LEACH LINES <br />LEACHING CHAMBERS <br />" �� <br />Amount <br />Remiftedervice <br /># OF LINES <br />LENGTH OF LINES ' <br />ft <br />Permit ID# <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />L <br />ft PROPERTY LINE <br />ft <br />❑ <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 />❑ <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 />❑ <br />SUMPS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH f%yft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />DISPOSAL PONDS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH I <br />It <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />It PROPERTY LIN JUNft <br />❑ <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft <br />DEPTH SAA, ..- _ <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTy,�I14RA. �wziqu1N CO111UT.. ft <br />_..... _..__._. _ _ n -Al ,-. _ <br />rT UEP�0q pp--��• "If <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE�WMiWN <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 />WORKEW COMPENSATION LAWS. <br />SIGNED <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to Depth of 3 <br />COMMENTS `- <br />_ Employee ID# <br />PERMIT - Approved by <br />PE <br />Code <br />SC <br />INFO <br />Received <br />k <br />Amount <br />Remiftedervice <br />Date <br />Permit/ <br />Re ue t # <br />Invoice # <br />Permit ID# <br />22r1 <br />L <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />v <br />v <br />