Laserfiche WebLink
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 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 14 �y <br /> 9m � , CITY/ZIP i�- �+sr Z, <br /> CROSS STREET �D AP f-1 © PARCEL SIZE�' (/ p> <br /> {y���-�f �1 I d <br /> OWNER NAME F �`�W►7 �� VL I AM <br /> PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR T°Ik L � -�11���•TC� � PHONE <br /> y� / <br /> CONTRACTOR ADDRESS 600A4/,z) CITY/STATE/ZIP r-40',ac4 '15-5x- <br /> LICENSE <br /> 15-5xLICENSE 1 I C-42 1 C-36 OTHER {o- NUMBER I EXPIRATION DATE <br /> WATER TABLE DEPTH: i�U i y 1 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # T BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: I i NEW INSTALLATION :,0' REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE I COMMERCI 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 _'S ft LENGTH 40/ ft DEPTH I I It <br /> DISTANCE TO NEAREST WELL 1001 ft FOUNDATION 3'n ft PROPERTY LINE ( )r ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It <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 PROPERTT' INS ft <br /> , �a.Y.1,.., <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 48' OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE c_0-jjjc__)�0 r DATE <br /> T1,13 <br /> i <br /> l <br /> J <br /> EPA RTMENV USE ONLY <br /> Application Accepted By Date Area _� Employee ID# <br /> Final Inspection By -* J7 Date �IlzZZJ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: PiUSump Soil Character: <br /> COMMENTSI/C%FILt� �, <br /> PE Sc Received Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Cash emitted Service a uest# <br /> 42-01 ONSITE WASTE✓VFATER TRTMNT SY;TEM PERMIT <br /> 5/5/17 <br />