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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAOUIN GUUN1 Y ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL,920/9 9 -7697 FOR INSPECTIO EXPIRES 1 YEAR F M DATE IS QED <br />JOB ADDRESS LI (� -G/ L{ <br />CROSS STREET /r APN �Q '^ r / J PARCEL SIZE <br />OWNER NAME <br />OWNER ADDRESS Z v'< % <br />CONTRACTOR <br />CONTRACTOR ADDRESSx <br />LICENSE 1 C-42 C-36 OTHER <br />til -cue'/', <br />i. <br />TE/ZIP <br />PHONE <br />a <br />A <br />le -77 CITY/STATE/ZIP D <br />NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />L.' PERC TEST # <br />Check#/ <br />I C h <br />BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION <br />REPAIR/AUDITION <br />ENGINEER DESI ED/ALTEERNATI <br />REPLACEMENT <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />DESTRUCTION <br />INSTALLATION WILL SERVE: I ! RESIDENCE <br />L COMMERCIAL <br />LI OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ 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 <br />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 CALIFORNIA CONTRACTORS <br />STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSAUION L S. <br />MI IMU H ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />AA % <br />SIGNED 'L TITLE DATE <br />EPA RTMENT E ONLY <br />Application Accepted 6y Date__Area Employee lu#_�� <br />Final Inspection By ` i' Date 11 SPE IAL PERMIT -Approved by <br />Character of Soil to Dep h of 3 t: Pit/Sump Soil Character: <br />COMMENTS ��er (,P1- r -P inn I�� 1A�. '�-c4 4�:11,ptk,,t) raU <br />b y r b n/, , �� a ep,L ""�q V- I N -k' <br />PE <br />Code <br />SC <br />INFO <br />Received <br />Bv <br />Check#/ <br />I C h <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />22� 1 <br />:&V <br />t -,A, ► <br />S Lr <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />