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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 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP ��. 4 <br /> CROSS STREET � L „�`�.- .,'�-s `�^�(yp.� APN ' PARCEL SIZE - p <br /> C7C�y <br /> OWNER NAME PHONE v� <br /> cn <br /> OWNER ADDRESS CITY/STATE/ZIPe <br /> CONTRACTOR PHONE -0?—/4Z T } <br /> CONTRACTOR ADDRESS _ -CITY/STATE/ZIP �7 GCJ� 9JG� � <br /> LICENSE LII.IC-42 I I C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST # BUILDING PERMIT# LAND USE/APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESI NEDIALTERNAT E <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: I RESIDENCE I COMMERCIAL 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 PAVp,�: ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LiRsl* ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH CD ft <br /> DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY It <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH 0— 19 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTYftn-- <br /> ^ ft <br /> 11 if%'U" yft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH QC <br /> AR <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE TMENT 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 /> MI IMUM 4g HOUR ARYANCE NOTICE REQUIRED FOR IN CTIONS-PLEASE CALL 209 953-769 <br /> SIGNED TITLE -0AT <br /> 117-1-41 <br /> DEPARTMENT SE OvLyjlpl <br /> q <br /> Applicatio ccepted B Daterea / Employee ID#� � G <br /> Final Inspection By Date I SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 fft: Pit/Sump Soil Character: <br /> COMMENTS •n'1 I r % <br /> PE Sc Received Check# Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B as Remitted Service Request# <br /> Z 5100 0L A?-Qq <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />