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60 <br />Q <br />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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 16 1 c `, /_-CIITY/ZIP �J M� C �! Q'10 <br />CROSS STREET �J (�I s-_` /U Ip? C`!I V <br />�( APN 0 7 (j;- 04 �l PARCEL SIZE <br />OWNER NAME M,4 JZ (7 FnrJ �% 11A1�/ PHONE 2-0 ^ <br />OWNER ADDRESS S� / 2�F /' 1�It � C� 5 CITY/STATE/ZIP ��67-3-?-7-Z7;! <br />OC %'�� `_a Z �S <br />CONTRACTOR PHONE 7� 67-3- ?- 7-Z <br />CONTRACTOR ADDRESS CITY/STATE/ZIP OAgk .. <br />LICENSE I I C-42 Il C-36 OTHER <br />NUMBER EXPIRATION DA <br />'t' MAY <br />WATER TABLE DEPTH: i ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />I I PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # J <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DER "t <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION Ff DEPARTMEWr <br />INSTALLATION WILL SERVE: RESIDENCE L COMMERCIAL LI OTHER <br />NUMBER OF LIVING UNITS: I _ NUMBER OF BEDROOMS: 97 NUMBER OF EMPLOYEES: <br />SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY (Zi�O gal # OF COMPARTMENTS____ <br />CAPACITY gal # OF COMPARTMENTS <br />1 <br />DISTANCE TO NEAREST: WELL1 V 0 ft FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />( <br />LEACH LINES <br />LEACHING CHAMBERS <br />r <br /># OF LINES <br />LENGTH OF LINES ft <br />Permit/ <br />Service Request # <br />Invoice # <br />DISTANCE TO NEAREST <br />WELL J f ft <br />FOUNDATION 40 <br />) <br />ft PROPERTY LINE I U / ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />F UINDTION <br />ft PROPERTY LINE ft <br />( <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft <br />DEPTH 25 / ft <br />DISTANCE TO NEAREST <br />WELL. ft <br />FOUNDATION So Y <br />ft PROPERTY LINE 1 U 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 />Ltv <br />MINIMUM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED h A7Gf/d ' TITLE �L� s � DATE <br />Application Accepted B <br />Final Inspection By <br />Character of Soil to Depth of 3 Ft: <br />COMMENTS <br />DEPARTMENT USE ONLY 1C,n <br />'/1_ Date 8 Area Employee ID# <br />Date Z&/ 2;�" Ll SPECIAL PERMIT - Approved by <br />Pit/Sump Soil Character: <br />PE <br />Code <br />SC <br />INFO <br />Received Che <br />Cas <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />4,11I <br />�S .` <br />5 <br />99001,10 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />