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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT F`"' <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT FALL 209 953-7697 FOR INSPECTIQ S EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS ( CITY/ZIH' l <br />CROSS STREE ` APN 'J�s In PARCEL SIZE <br />09*77 <br />OWNER NAME { tq -M79 <br />KM C &RA-AJ4'4TYI PHONE ` t <br />OWNER ADDRESS A J t <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />LICENSE i)jC-42 1_1 C-36 OTHER <br />PHONE 6'T -IL. <br />CITY/STATE/ZIP <br />NUMBER i OCA i 1 EXPIRATION DA' <br />It ti <br />WATER TABLE DEPTH: — j U r co it GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # I BUILDING PERMIT # 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 ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br />SEPTIC TANK TYPE/MFG t L CAPACITY gal # OF COMPARTMENTS_ <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />r <br />DISTANCE TO NEAREST: WELL _ �0 it FOUNDATION 110 it PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES --�, LEACHING CHAMBERS <br /># OF LINES[�— <br />LENGTH OF LINES 4- it <br />l� <br />DISTANCE TO NEAREST WELL �T <br />ft FOUNDATION 1'" <br />it() PROPERTY LINE it <br />❑ FILTER BED WIDTH it LENGTH <br />it <br />DEPTH 13A V,. it <br />DISTANCE TO NEAREST WELL <br />it FOUNDATION <br />it PROPWft/.L� it <br />❑ MOUNDED WIDTH ft LENGTH <br />it <br />�+. <br />DEPTH 9��(� �ytwn it <br />DISTANCE TO NEAREST WELL <br />it FOUNDATION <br />it PROPItINLIC{E it <br />❑ SUMPS WIDTH ft LENGTH <br />ft <br />DEPTH aar���YY it <br />DISTANCE TO NEAREST WELL <br />it FOUNDATION <br />it P 4 it <br />ElDISPOSAL PONDS WIDTH ft LENGTH <br />ft <br />DEPTH I ML, -- M-fxUNN it <br />TO NEAREST WELL <br />it FOUNDATION <br />utzDISTANCE <br />it PROPERTY LIMR741 ft <br />SEEPAGE PITS NUMBER WI TH <br />ft <br />DEPTH it <br />DISTANCE TO NEAREST WELL + <br />it FOUNDATION .j' <br />ft PROPERTY LINE it <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 <br />STATE LICENSE BOARD AND THAT <br />I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />DATE <br />Application Accepted <br />Final Inspection By -j <br />Character of SoiClt- <br />of <br />COMMENTS <br />3 Ft: <br />71 Ir Area. Employee ID#� <br />❑ SPECIAL PERMIT - Approved by <br />ump Soil Character: <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Check#Amount <br />Permit/ <br />emi ed Date Service Request # <br />Invoice # <br />Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />r <br />