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ONSITE WASTEWATER TREA"rMENT SYSTEM PERMIT P <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-KEFUNDABLE PE IT GALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEARFROMDATE ISSUEI <br />,,JOB ADDRESS 7/ U-.7 Ux .11e j77 e %CIT�Y/ZIP � / <br />CROSS STREET �fQ.G1 r V ��/W �C 1A/PN / ��'��J/ GL3PARCEL SIZE <br />OWNER NAME 7eN <br />O'�j L� L11� e PHONE IZIOf-15V- 2.417Z <br />7 <br />OWNER ADDRESSSyJ S CITY/STATE/ZIP <br />CONTRACTOR / �/w�Q9�%�»/�'� PHONE..rr�T�-- �O %/�J t,Ij <br />CONTRACTOR ADDRESS !! / �/ o'el /� /p CITY/STATE/ZIP / ^A7 e- 1 C a ' <br />LICENSE 11 C-42 FIA36 OTHER NUMBER / 0 /� _ EXPIRATION DATE T <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />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 ?C DESTRUCTION ��j� P411r <br />INSTALLATION WILL SERVE: ❑ RESIDENCE L COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ <br />❑ <br />SEPTIC TANK <br />GREASE TRAP <br />LIFT STATION <br />TYPE/MFG <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />SIZE TYPE OF PUMP <br />ft <br />CAPACITY <br />CAPACITY <br />FOUNDATION <br />❑ PKG TX PLANT <br />❑ <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />ft <br />❑ <br />LEACH LINES <br />LEACHING CHAMBERS <br />B <br />Remitted <br /># OF LINES <br />Service Request # <br />LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />79-7 <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH _ <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />SUMPS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />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 />Application Accepted By <br />Final Inspection By <br />Character of Soil to D hof <br />COMMENTS <br />TITL <br />DATE ,P <br />r' DEPARTMENT U Fg,016L.Y /�%��f <br />Date Ly Area �L?�/`LIT <br />Employee ID#V VDate "01 ElSPECIAL P - Approved by <br />Pit/Sump Soil Character: <br />0el <br />PE <br />Sc <br />R ceived <br />Check# <br />Amount <br />Date <br />PermiU <br />Invoice # <br />Permit ID# <br />ode <br />INFO <br />B <br />Remitted <br />Service Request # <br />�0 <br />79-7 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />T, <br />