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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> USAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> Nog-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP <br /> CROSS STREET _ APN_ PARCEL SIZE p <br /> 0 <br /> SJ <br /> OWNER NAME PHONE <br /> OWNER ADDRESS _ CITY/STATE/ZIP r <br /> CONTRACTOR _. PHONE <br /> CONTRACTOR ADDRESS CIN/STATE/ZIP <br /> LICENSE UCC-42 11i C-36 OTHER NUMBER EXPIRATION DATE 1 <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: _i NEW INSTALLATION, REPAIR/ADDrr1ON ENGINEER DESIGNED/ALTERNATIVE <br /> +� REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> 13 SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL SG 1 ft FOUNDATION ft PROPERTY LINE IS'; It <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKGTX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES It <br /> DISTANCE TO NEAREST WELL It FOUNDATION 2" L ft PROPERTY LINE �' , ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH It LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <br /> ❑ SUMPS WIDTH It LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL It FOLNDATION _It PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH w ft DEPTH It <br /> DISTANCE TO NEAR /-y/ELL It FOLi40ATI,ON ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER-7 WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST 'WELL It FOUNDATION G ) 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 COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE /1 <br /> NTI <br /> T <br /> G p T EN7 <br /> l' H <br /> t <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date 1 Area 14 Employee ID# <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PIVSump Soil Character: <br /> COMMENTS c7 <br /> A(44 S <br /> PE SC Received Check#/ Amount Dace Permit/ Invoice# Permit ID# <br /> Code INFO B Cash Remitted Service Request# <br /> -- -a. <br /> 42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />