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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 />9ALL <br />09 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEARC FROM DATE ISSUED <br />JOBADDRESS I <br />CITYYI IP f' S��(1c" <br />CROSS STREET kwC <br />•/a <br />% <br />APN ���7U���+ <br />PARCEL SIZES <br />INSTALLATION WILL SERVE: LI RESIDENCE <br />11 COMMERCIAL <br />L� OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />OWNER NAME Cw 44`c4_ <br />6,q <br />OY <br />(,3 <br />PHON"&" <br />�`��j 1 /2 <br />OWNER ADDRESS 6 �1 <br />'� N <br />e( e4'' `l CIT S ATE/ZIP 4,1' <br />/� <br />i/X <br />/0 /v <br />//� <br />t <br />❑ LIFT STATION SIZE _ TYPE OF PUMP <br />CONTRACTOR <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />PHONEdU <br /># OF LINES <br />!\ <br />CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />ft FOUNDATION <br />LICENSE I I C-42 I I C-36 OTHER <br />❑ FILTER BED WIDTH ft LENGTH <br />NUMBER Jl _ EXPIRATION DATE <br />DEPTH ft <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />PERC TEST # BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION <br />REPAIR/ADDITION <br />ENGINEER DESIG/NED/ALTERNATIVE <br />REPLACEMENT <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />DESTRUCTION v <br />INSTALLATION WILL SERVE: LI RESIDENCE <br />11 COMMERCIAL <br />L� OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />,r <br />LrJ SEPTIC TANK TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE _ TYPE OF PUMP <br />❑ PKG TX PLANT ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ FILTER BED WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />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 <br />THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS <br />STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSAIION LAWS. <br />/MVM H)OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953--7697_ <br />SIGNED <br />TITLE A<,$ / C# <br />DATE /ff Kl <br />Application Accepted B <br />Final Inspection B;/ <br />Character of Soil to Depth <br />COMMENTS C -ii Z <br />3 Ft: <br />Date <br />Area 4�— i <br />� ❑ SPECIAL P <br />it/Sump Soil Character: <br />Employee ID#� <br />-Approved by <br />PE <br />Code <br />Sc <br />INFO <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />emitted Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />