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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-76(97 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Vl L) / G ��`�" v'' �- �< CITY/ZIP L►� ( v <br /> CROSS STREET �� G.. APN Q 3 ICJ VV / PARCEL SIZE ✓ �C p� <br /> i L� d <br /> OWNER NAME 1 1� �-/ PHONE Phi <br /> OWNER ADDRESS I vJ �C� �VNN� --CITY/STATE/ZIP ��7�+1 <br /> CONTRACTOR 7D 1 1 r j JC�11� ()-e _ PHONE `i�O,�U`� ,•Jt JJ'�1•� `� <br /> CONTRACTOR ADDRESS �X 11 �7C —CITY/STATE/ZIP �(, t, q5-Z'40 <br /> LICENSE C-42 ' C-36 OTHER A, NUMBER J J EXPIRATION DATE 1 13v I z i <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> PERC TEST #, BUILDING PERMIT# LAND USE APPLICATION# r <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED IALTERNATIVE <br /> J <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION -" <br /> INSTALLATION WILL SERVE: /° RESIDENCE COMMERCIAL 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 ►'V 1 r{ rr/\'r� #OF LINES LENGTH OF LINES �' It <br /> DISTANCE TO NEAREST WELL I�y 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 ; 'A <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> SUMPS WIDTH It LENGTH ft DEPTH AdA 4 <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH c.�OA(]i,,.. <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINENEA/p0 AAiU <br /> ONfty <br /> LlSEEPAGE PITS NUMBER 1 WIDTH 3C7 ft DEPTH 2-5 FpAR`ITg'AL fTt <br /> DISTANCE TO NEAREST WELL I�� ft FOUNDATION t`� ft PROPERTY LINE t J ► ft <br /> I HEREBY CERTIFY THAT 1 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 /> MINIMUM 48 UggEnDVANCE NOTICE REDMBERFOR INSPECTIONS--/P�^LEASE CALL 209 953-7697 <br /> SIGNED TITLE ��S U �- l DATE -Z4' 7-3 <br /> a ic <br /> J <br /> G <br /> a <br /> 3 <br /> j/ DEPARTMENT USE ONLY <br /> Application Accepted B �zz � Date Z'O Area I � Employee ID# <br /> Final Inspection By Date ZVwZD I SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received Date�e Amount Permit/ Invoice# Permit ID# <br /> Code INFO B as Remitted Service Re uest# <br /> ,;10 i 12 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />