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t ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> F 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 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �c�%� y /SC�4J(�� L CITY/ZIP <br /> CROSS STREET DLAc'iG � APN D O– 5� PARCEL SIZE <br /> d <br /> OWNER NAME���r � � t% PHONE <br /> OWNER ADDRESS-7 1.A' � Al. aC�'b�. �rr®y —CITY/STATE/ZIP _j&A PU <br /> CONTRACTOR G.�NlfYl1L / ��i��. i7L PHONE 36y SJy7/ <br /> CONTRACTOR ADDRESS /G �J/SU vt> t�i� CITY/STATE/ZIP GGGU <br /> LICENSE L/C-42 _111C-36 OTHER NUMBER ys`1O S�� EXPIRATION DATE//J <br /> 1 <br /> WATER TABLE DEPTH:����ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> IJ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I NEW INSTALLATION I REPAIR/ADDITION ENGINEER DESIG EDIALTERNAT VE <br /> REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: 11 RESIDENCE F1 COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: I <br /> NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br /> SEPTIC TANK TYPE/MFG ^/� CAPACITY G gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE To NEAREST: WELL ft FOUNDATION ft PROPERTY LINE �70 ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> f - LEACH LINES I LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE S ft <br /> FILTER BEI) ;t_ WIDTH ft LENGTH �S ft DEPTH �� ft <br /> q , DISTANCE TO NEAREST WELL 1/0 ',0­ 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 YAaL_s o._ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH r� ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE�kRnv <br /> ® ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH SAAIJ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY/j cn,,_ ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCCCORDANC�OUVIli""N <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 ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 <br /> SIGNEDy/—�iG'G TITLE �s�/x/ts��'= DATEri <br /> i Z <br /> f <br /> �&�SZ <br /> L <br /> U y v1w <br /> V� h <br /> EPARTMENT SE NLY <br /> Application Accepted By Date Area Employee <br /> Final Inspection By Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> C0MMENTSG <br /> L <br /> PE SC Received h Amount Date Permitt Invoice# Permit ID# <br /> Code INFO ash Remitted Service Reg uest# <br /> I-141-All S0100 I <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />