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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOi0tim 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 Vll _ _(/ /—� -- CITY/ZIP <br /> Ci1nSSSTFET us ._ APN lQS- I ✓ - PARCEL SIZE(g1.7� p <br /> OWNER NAME L c, tb Y`DPHONE JD�j �3 i �-%l0�� 5�,• <br /> �� ��c �J�/eta/ T ATEJZIP <br /> OWNER ADDRESS <br /> CONTRACTOR Se\ _- A _ - PHONE_ (�(�ab <br /> CONTRACTOR ADDRESS - ...C(Y/STATE/ZIP <br /> LICENSE G C-42 L C-36 OTHER NUMBER _ _EXPIRATION DATE--- <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X_— Y <br /> ❑ PERC TEST M_ BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION 41EPM ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE ! COMMERCIAL l I OTHER <br /> NUMBER OF LIVING UNITS: __,(/(NNUMBER OF BEDROOMS: __ ��__ NUMBER OF EMPLOYEES; <br /> ❑ SEPTICTANK TYPE/MFG —�t7�[A — _ CAF'ACITY_____._.-....--__ gal If OFCOMPARTMENTS <br /> ❑ GREASETRAP TYPE/MFG __ _ CAPACIrY __ • gal If OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ___ It FOUNDATION -_--__ _ It PROPERTY LINE_it <br /> ❑ LIFT STATION SIZE TYPE OF PUMP_ Cl PKG TX PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> /t <br /> _01- LEACH LINES LEACHING CHAMBERS_ _., If OF LINES LENGTH OF LINES_ S> it <br /> DISTANCE TO NEAREST WELL,re-e.. <br /> it FOUNUAIION (y r <br /> ._-_- _�Q.`_.. It PROPERTY LINE it <br /> ❑ FILTER BED WIDTH __ _ -_it LENGTH_ _-__ft DEPTH it <br /> DISTANCE TO NEAREST WELL___- -_ It FOUNDA11ON ____ it PROPERTY LINE- it <br /> ❑ MOUNDED WIDTH ___It LENGTH_ __ _ it DEPTH- it <br /> DISTANCE To NEAREST WELL —,-,.,. it I OUNDANON, --_ ,_-it PROPERTY LINE it <br /> ❑ SUMPS WIDTH _.-It LENGTH—_, _- it DEPTH-__, ft <br /> DISTANCE TO NEAREST WELL — It FOUNOATIOH .—_ it PROPERTY LINE it <br /> ❑ DISPOSALPONDS WIDTH _ __ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL __,. It t'OU�NDITION _ it PROPERTY LINE It <br /> SEEPAGE PITS NUMBER L__ -_._ WIDTH `,I1_- __ _It DEPTH �S r It <br /> DISTANCE TO NEAREST WELL_�Jff�_- It FOUDIDAIION - R PROPERTY LINE It <br /> 1 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI UM 2 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-�7j697 <br /> SIGNED _ TITLE_h'1c1.4- f''- DATE If-U <br /> tAA <br /> _ O 1Y <br /> D pq <br /> rgTMEN l NLY <br /> Application Accepted By Date- „ _ -_ _.L_ __ Area_ C Em Io ee IDM <br /> p vFnal Inspection ey ;y yDate 7�t`��/_ -_-__ ! SP CIAL ERMIT-App oved by <br /> Character of Soil to Depth of 3 Ft:— '7 " _ _ Pit/Sump Soil Character: `' 7�> L <br /> COMMENTS <br /> �yDt7fr 11 _Fly..�n�- <br /> wt�i� tt(� !LE til'�,1 [��A�U`ll GlaLt�•t�1-Q�1 [G,wf! 4KIS�(m.c� <br /> PE SC Receivedhec Amount Permit! <br /> Dale Invoice R Permit IDM <br /> Code INFO ash Remitted Sarvic--e�R�eque�t k <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 575/17 <br />