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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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 EAR/� � FF�'ROM DATE ISSUED <br /> ? <br /> JOB ADDRESS 0 `�� ✓� CITY/ZIPyU�� <br /> CROSS STREET APN / ' PARCEL SIZE V. p <br /> OWNER NAME1/•�!� rEi�C/�lC/� PHONE v� <br /> cV q-17377 <br /> OWNER ADDRESS /'/�//�7L/) C�� � ' CITY/STATE/ZIP / <br /> CONTRACTOR �r!/DJdC �A7 r �[fc�l J PHON45` -O- �,/�s,g I - ✓ 2 ( <br /> I ifCONTRACTOR ADDRESS �f7 �1��', v/� CITY/STATE21P ///n Vl 6,4 <br /> LICENSE I I C-42 I C-36 OTHER NUMBERIr <br /> EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> 1_I PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I NEW INSTALLATION i REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM d1k DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE I I COMMERCIAL I I 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 NEAREST WELL ft FOUNDATION ft PROPERTY ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ® ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN gyp ML�l ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH 1.4p� ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE U ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH SAN JOq ft <br /> CIVV <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PR64 111��mENr',, ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH <br /> 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 48 HOUR A VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE DATE <br /> DATES^� <br /> • EPARTMENTUS ONLY <br /> Application Accepted y Date Area _ �� Employee iG# <br /> Final Inspection By. Date ❑ SPE IAL PE IT-Approved by <br /> Character of Soil to Depthf 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS 0 �C �Y <br /> PE SC Received hec Amount PermiU <br /> Code INFO By _ ash Remitted Date Service Request# Invoice# Permit ID# <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />