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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SANIIJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> • <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> SOB ADDRESS CITY/ZIP � flZ <br /> y� h <br /> CROSS STREET 't-/ / /7 e j" PN�VZ-qV/, <br /> PARCEL SIZE y <br /> v <br /> /�L/ / ��L Q m <br /> OWNER NAME i { PHONE / T� % A <br /> OWNER ADDRESS �l� 7 (v )� CITY/STATE/ZIP 51�4A4 C� % 411. /J <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE I C-42 I I C-3/66 OTHEER""j� NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: V/( ��+ ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> 1 PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: ENRESIDENCE LL COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: / NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG v CAPACITY 0�� gal #OF COMPARTMENTS_ <br /> ❑ GREASE TRAP TYPE/MFG �f �(\ _ CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL Lamk `-' -t 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 LEACHING CHAMBERS #OF LINES 4 LENGTH OF LINES 0 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINEft <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 It <br /> ft DEPTH Z <br /> DISTANCE TO NEAREST WEL 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/IION LAWS. <br /> MINIM 44 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE_�� DATE <br /> P ;Vr Lw <br /> O <br /> P A R T M E&T IJ S O t4 LY A <br /> Application Accepted B Date Areae_! Employee ID# <br /> Final Inspection By Date 11SPECIAL PERMIT-Approved by <br /> Character of Soil to th 3 t: PiUSum �oiMaracter- <br /> is <br /> COMMENTS o Q4t Y iT fI ' <br /> t6 z COOT 45e' 540rf— r I(v T -f 0.1f i A tw' I <br /> 0. SSS h i �y ✓: u ►�oC t l4 Yfit- q;' <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO By Cash Remi ed Service Request# <br /> l9 el z'+� <br /> Den <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />