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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 CALL 209 953-7697 FOR INSPECTIONS / EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS �800 0 Ye CITY/ZIP C/-Od r, G� -1 S <br />CROSS STREET 4z4-lewiof, �G e, APN 0'5 I Vy ( J PARCEL SIZE ' C <br />OWNER NAME W Q0-0141bt,0 T" PHONE l , <br />OWNER ADDRESS/ � �/ 0 IS /\ r CITY/STATE/ZIP Lp�7/,, (A <br />' <br />CONTRACTOR ( 4 1 V�� C_ PHONE O / <br />CONTRACTOR ADDRESS �� � - 6�sa .1 -CITY/STATE/ZIP L/-041 <br />LICENSE I 42 1 1 C-36 OTHER NUMBER �T� EXPIRATION DATE <br />WATER TABLE \DEPTH: -� ft GEOGRAPHICAL INFORMATION: Coordinates X <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEEF6R*16N D /ALTEFFNAftE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTICA -901V <br />INSTALLATION WILL SERVE: RESIDENCE LCOMMERCIAL OTHER 17i <br />NUMBER OF LIVING UNITS: / nNUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br />% /'� <br />SEPTIC TANK TYPE/MFG I. 7OC /" CAPACITY 14706 gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG _ CAPACITY gal # OF COMPARTMENTS <br />i <br />DISTANCE TO NEAREST: WELL / $�O ' ft FOUNDATION S ft PROPERTY LINE 30 , ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />XLEACH <br />LINES <br />LEACHING CHAMBERS <br /># OF LINES 3 <br />LENGTH OF LINES SS / ft <br />Date P mIU <br />Service Request # <br />Invoice # <br />DISTANCE TO NEAREST <br />WELL /(&0 <br />ft FOUNDATION /0 <br />ft PROPERTY LINE 3Q ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft 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 <br />ft 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 <br />It 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 <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />SEEPAGE PITS <br />NUMBER J <br />Q <br />WIDTH <br />// ft <br />DEPTH�i-5 / ft <br />DISTANCE TO NEAREST <br />WELL I60 ' <br />ft FOUNDATION <br />ft PROPERTY LINE 30 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 />ED <br />Application Accepted By <br />Final Inspection By <br />Character of Soil Dept of 3 <br />OMMENTS <br />el�CAT', (-_ t <br />c zMn <br />i0 -a--t 6 <br />TITL <br />DATE 5'4F -"e <br />DEPARTMENT USE ONLY 1 I <br />Date S- 1V f Y Area / 9 C1 Employee I D# <br />Date Zcg ❑ SPECIAL PERMIT -Approved by <br />Pit/Sump Soi Char Iter: <br />S IDa , <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />'(Checkjo <br />Amount <br />Remitted <br />Date P mIU <br />Service Request # <br />Invoice # <br />Permit ID# <br />T <br />ni <br />Y <br />n <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />