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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P <br />SAN JOAOUiN+COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />Nom -REFUNDABLE PERMIT CALL 9 953-7697 FOR INSPECTIONS EXPIRES 1 Y AR FROM DATE ISSUE[ <br />JOB ADDRESS CITY/ZIP-Z2 <br />CROSS STREET / AP % PARCEL SIZE -5 <br />3 <br />OWNER NAME C5 L (G CQ % U ll[ + C� PHONE <br />r" �/ [ D CITY/STATE/ZIP 1L4 ��� <br />OWNER ADDRESS <br />C 0,NTRACTOR �J G 142 <br />�-/ PHONE <br />CONTRACTOR ADDRESS 14 �`fa CITY/STATE/ZIP <br />LICENSE I I C-42 I I C-36 OTHER NUMBER XPIRATION DATE <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATI N: COor nates X Y <br />PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION R PAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE LL COMMERCIAL 11 OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: S NUMBER OF EMPLOYEES: <br />SEPTIC TANK <br />TYPE/MFG / <br />_ CAPACITY �/ f ,5,0 gal <br /># OF COMPARTMENTS 1= <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY gal <br /># OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL �I�7n ,- <br />ft FOUNDATION iS T ft <br />PROPERTY LINE L ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES �S ;S ft <br />DISTANCE TO NEAREST WELL;IVd �_ ft FOUNDATION /!2 ft PROPERTY LINE ft <br />❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br />"4 T MEIN <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE p <br />❑ MOUNDED WIDTH ft LENGTH ft DEPTH ElV1�D <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE_/_ ft <br />El SUMPS WIDTH ft LENGTH ft DEPTH �. � 201&gt <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINAe+rel JOa� ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH E�IROUNnil' <br />DISTANCE TO NEAREST WELL j/ ft FOUNDATION ft PROPERTY LINE EI'ARTMEN�t <br />SEEPAGE PITS NUMBER �� WIDTH ft DEPTH .7 / ft <br />DISTANCE TO NEAREST WELLd t ft FOUNDATION AP � ft PROPERTY LINE�44 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 COMPENSA=ON LAWS. <br />MINIMU 'HOUR ADy4NC&gN0T1CE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 9537697 <br />SIGNED TITLE l^-1"' n DATE <br />Application Accepted <br />Final Inspection By_ <br />Character of Soil to 6 <br />COMMENTS _ <br />Date <br />Date <br />I S Eb. N Y %lri^t "r1V//.ei 100 / <br />Area Employee ''I DD# <br />❑ SPECIAL PERMIT - Approved by <br />Pit/Sump Soil Character: <br />PE <br />SC Received <br />INFO B <br />&SqcW <br />Cash <br />Amount <br />emi ed <br />Date <br />Permit/Code <br />Service Request # <br />Invoice # <br />Permit ID# <br />7Z9 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />