SR0079576 - Laserfiche WebLink

Home Browse Search

ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS / � EXPIRES 1 YEAR FROM DATE ISSUED S q JOB ADDRESS cu n \ L CITY/ZIP � ! 1P / o YI 4-e c ci J S 0 -1 0 - 03 . v3 CROSS STREET AP PARCEL SIZE �Q MO f,/� 1 U ,( 1 9 a OWNER NAME • I J MOFX A(, L-A k-r PHONE V S� l /+ 9 J�J �y �[� /, OWNER ADDRESS O f OC 7 1 Cyo-e r I e C.-1 /X/`-e CITY/STATE/ZIP L,�? '( ? TSr�l RdP /�t4 4) 330 CONTRACTOR PHONE °l I l7 J '�l J U( /-3' CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE I I C-42 I i C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE L COMMERCIAL 1J OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENS41JON LAWS. 1/8 MINIM M 2*HOUR A VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEA SE CALL 209 953-7697 p SIGNED , TITLE O(c 9 )U 1. l C DATE T D 18 �SANJ)A U H N EP I TA L TY NT PARTME T SE O Y Application Accepted By Date 0 Are#PCIAL Employee ID# Final Inspection By Date r%� -i PERMIT-Approved by Character of Soil to De th of 3 Ft: Pit/ ump Soil Character: COMMENTS C-) .JAelyl� ekc, MK Q� cY PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# Code INFO By Cash Remitted Service Request# Lb 42-01 '"� 23 0gte ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17