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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P / "' <br /> SAN JOAQI„IN 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 /> 4012140121ADDRESS ltwy,� i� �!/ CITY ZIP r/e q sc - &,q4 so AP C�sA `7 cSZ3 <br /> CROSS STREET L20 /✓�✓ D r� APN q3 -�/y /� PARCEL SIZE �� p <br /> OWNER NAME PHONE �r <br /> SJZ7 v <br /> OWNER ADDRESS Q— +'` 9PI:ITY/STATE/ZIP /,'' C�-'7k-� <br /> CONTRACTOR �`TS W[z LJ�I�/�-' _ ' - PHONE �Q I) �3-- -776,P- <br /> CONTRACTOR <br /> L /6, - <br /> CONTRACTOR ADDRESS L-f 6 L-l3 ��J�_ CITY/STATE/ZIP <br /> LICENSE 11 C-42 I I C-36 OTHER NUMBER P�{670 EXPIRATION DATE 12 PI .30 <br /> L- <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: CoordI ates X Y <br /> 11 PERC TEST # A BUILDING PERMIT# Oo LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION R AIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: /*P RESIDENCE El COMMERCIAL Ll OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG CAPACITY Q O gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES LEACHING CHAMBERS _ #OF LINES LENGTH OF LINES_ ft <br /> DISTANCE TO NEAREST WELL 1770 ft FOUNDATION t�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 /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL 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 COMPENSATION LAWS. <br /> MINIM M OUR V OTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE�t r--A � Oa K 61—C--DATE <br /> T <br /> /R <br /> Op <br /> F <br /> n nTPr'E NA 11SE .^. 'L Y <br /> Application Accepted ByDate Area Employee ID#� <br /> Final Inspection By_ � t� Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: _ <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO BY Cash Remitt d Service Request# <br /> l mac- �3 S <br /> 42-01 OZ' 1 ����— ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />