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• ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JO 1QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1865 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 �oL WEST LO/2FA/ee/-1 4> • CITY/ZIP -Tisk <br /> CROSS STREETGGx� APN 23 9-142 -t)3 PARCEL SIZE ,/ <br /> OWNER NAME 4AQ a L ! /ZA/�� e PHONE;(-/—* 4 <br /> 01 891 mn <br /> q { � <br /> OWNER ADDRESS / '/Tlf��rV A/ R A CITY/STATE/ZIP 5T1 OC4aTbd 9) <br /> CONTRACTOR_CA If- n'jK1jrULT/Ayf _ PHONE -2t-'' <br /> CONTRACTOR ADDRESS O ' 60 x 379¢ CITY/STATE/ZIP / (�{/2L�� Ga� 9rJQ1 <br /> LICENSE C-42 C-36 OTHER—Re--g NUMBER e 7S EXPIRATION DATE_ <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION#&A /.Odl,O/O <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: I I RESIDENCE ❑ COMMERCIAL OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG _ CAPACITY 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 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 NEARESTWELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH p- ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY � ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH� , ' ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPER14 LINE Q ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH y�y�� y ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PR0PER`I'R(. O co/,. <br /> ft <br /> ',-q ' <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANC t��,i SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LIC SE 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 /> MINI JM 48WQVR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE �'/✓�`�i✓�/NE�/t DATE <br /> n F <br /> A <br /> s 4 .11 . T <br /> o ! <br /> 5 <br /> O Q D <br /> EPARTMENT USE ONLY �� ��y]c� <br /> Application Accepted By Date Z Area J /77 Employee ID# <br /> Final Inspection By ITVI r Date I SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth,'o{3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Permit ID# <br /> C de INFO Cash Remitted Service Request# <br /> 5 2 �3 b5 I 'Z 2-1 -119 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />