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4 <br /> 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 y�CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE IS ED <br /> JOB ADDRESS L40 S is«T P47 CITY/ZIP S t-,C- Y A .C-.4- <br /> CROSSSTREET ,^ SLS APN PARCEL SIZE p <br /> 0 <br /> ,t y G p z <br /> OWNER NAME Srr'�-'+ LA 1 Jm' .'I U '/— sr<C:y--Y &7 PHONE r1�✓t -� <br /> OWNER ADDRESS �� CITY/STATE/ZIP <br /> CONTRACTOR (LGA l/-Gl(Ll (` PHONE 7 <br /> CONTRACTOR ADDRESS �i'� 160'Kc S CITY/STATE/ZIP oun-,,-G et- f z.✓f' ci <br /> LICENSE I I C-42 1 J C-36 OTHER NUMBER r EXPIRATION DATE / e� <br /> WATER TABLE DEPTH: �ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# 1 `' t 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: t]'<ESIDENCE ❑ COMMERCIAL Ll OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:_ett NUMBER OF EMPLOYEES: <br /> 4,-'!�IEPTIC TANK TYPE/MFG L CAPACITY 1� '60k gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY ^^ gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL Z" ft FOUNDATION_ .A o ft PROPERTY LINE C" ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES LEACHING CHAMBERS #OF LINESLENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL _: N a ft FOUNDATION . ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <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 /> V ""PAGE PITS NUMBER I WIDTH 1., 1, <br /> ft DEPTH ':;LC-1 x ft <br /> DISTANCE TO NEAREST WELL__ ft FOUNDATION 1S'I ft PROPERTY LINE�6 t 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 /> SIGNEDTITLE L c�Z�- 3G 1t, 1� DATE-440 <br /> ~ <br /> fk <br /> n <br /> DEPA RTMENTU E N V <br /> Application Accepted By Date l Area Employee ID# <br /> d—ow <br /> Final Inspection By Date t �- d" ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PAYMENT- <br /> RECEIVED--- <br /> PE <br /> AYMENTRECEI EDPE SC Received hec Amount Permit/Code INFO B ash Rem'to Date Service Request# OCT <br /> Invoice# TVA, <br /> 3 i�- <br /> 4 JOAQUIN COUNTY'- <br /> HEALTH DEPARTMENT <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />