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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-REFUNDABLE PERMIT <br />CALL 209 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS J L t74 <br />'' Y <br />CITYRIIPV ! %-r-14 CA - 6-1C 4 <br />4J ' <br />CROSS STREET j ��,Q <br />gal # OF COMPARTMENTS <br />APN Z%* `'f - —11 o — 1 � <br />�j <br />PARCEL SIZE . 5 ✓ <br />OWNER NAME �/ %v� ( <br />/+ <br />/ FA 4 t <br />G <br />I�lr%Y 'f^� <br />PHONE $,"3iA'rr& <br />OWNER ADDRESSSCOV./' <br />OIL SEPARATOR (ENCLOSED SYSTEM) <br />CITY/STATE/ZIP <br />LEACHING CHAMBERS <br />CONTRACTOR Y/ I �1 <br />'C� ��_ <br />) <br />PHONE �^( <br />r <br />j=Gr <br />CONTRACTOR ADDRESS <br />`C L� �i <br />CITY/STATE/ZIP <br />J <br />&A $ei4 r C.A 5g3z <br />LICENSE I I C-42 C-36 <br />OTHER i <br />NUMBER 1 '� LJ5j EXPIRATION DATE <br />WATER TABLE DEPTH: `O ft GEOGRAPHICAL INFORMA <br />PERC TEST # _ BUILDING PERMIT # <br />TYPE OF WORK: NEW INSTALLATION R PAIF <br />X <br />LAND USE APPLICATION #_ <br />ENGINEER DE: <br />Y <br />_. REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL C- iSTHER - "N <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />TERNATIVE <br />fYb°EPTIC TANK <br />TYPE/MFG � L <br />CAPACITY z) o <br />gal # OF COMPARTMENTSA <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION �� <br />ft PROPERTY LINE of ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND <br />OIL SEPARATOR (ENCLOSED SYSTEM) <br />9—LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINE' <br />LENGTH OF LINES L—A ft <br />DISTANCE TO NEAREST WELL r ft FOUNDATION ft PROPERTY LINE rQ 1 ft <br />❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH 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 COMPENS ON LAWS. <br />MINIMUM HOUR 4DAIANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 95 7697 <br />SIGNED TITLE_ �Q..4 DATE r?)—/10& <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to Depth of 3 Ft: <br />COMMENTS <br />Area Employee ID#At� <br />1-1 SPE AL PERMIT -Approved by <br />Soil Character: <br />PE <br />SC <br />Received <br />Check#/ <br />Amount <br />Permit/ <br />Code <br />INFO <br />By <br />Cash <br />Remitted <br />Date <br />Service Request # <br />Invoice # <br />Permit ID# <br />i gd�6 <br />C <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />Ln <br />M <br />y <br />