Laserfiche WebLink
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 209 953-7697 FOR INSPECTIONS EXPIRE�S^1�vYEAR FROM DATE ISSUED <br /> JOB ADDRESS �-=� - A 7x I —"'�� CITY/ZIP _ �1 1 <br /> y rev � r� <br /> CROSS STREET APN PARCEL SIZE 1 r 3 S b 0 S °� 1 y <br /> _ p <br /> Ila v <br /> OWNER NAME ��J <br /> I - - -- —PHON 2®� 1 ' ! _ n <br /> rn <br /> OWNER ADDRESS �L CITY/STATE/ZIP <br /> CONTRACTOR __ PHONE <br /> CONTRACTOR ADDRESS - _ CITY/STATE/ZIP . <br /> LICENSE ❑ IC-42 ❑_C-36 OTHER _ NUMBER_— _EXPIRATION DATE_ <br /> WATER TABLE DEPTH: U ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> Ll PERC TEST # BUILDING PERMIT# I 0 0 LI 1 ')- LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> _ REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE I I COMMERCIAL I I OTHER <br /> NUMBER OF LIVING UNITS: I NUMBER OF BIA <br /> EDROOMS: .l _ NUMBER OF EMPLOYEES: <br /> f SEPTIC TANK TYPE/MF6CAPACITY gal #OF COMPARTMENTS 2— <br /> /❑ GREASE TRAP TYPE/MFG — _ CAPACITY _ gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION — It PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ElPKG TX PLANT L3SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES_ ft <br /> DISTANCE TO NEAREST WELL n "� ft FOUNDATION ft PROPERTY LINE ft <br /> �d b <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 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <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 — it PROPERTY LINE It <br /> SEEPAGE PITS NUMBER _ WIDTH_ `�L_ I! It DEPTH ` ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE -5 n T 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 /> MINIMUO 2,4 H0QR AD NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-76f97 <br /> SIGNED TITLE 1^ DATE I 10 I <br /> w <br /> F- <br /> Z <br /> y U1 <br /> 1 �o <br /> z <br /> W~ <br /> L <br /> DEPARTMEN USE ONLY <br /> Application Accepted y _ Date __ _ Area /C� `� Employee ID# G/ <br /> Final Inspection ByDate'6 12'3/707.) �l SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: _ Pit/Sump Sol!Character: <br /> COMMENTS JS) 19 . <br /> _ ix-th 11-6 <br /> Q <br /> PE SC Received Check#/ Amount Permit/ <br /> Code INFO B Cash Remitted Date Service Request# Invoice# Permit ID# <br /> I II r .5- 51 11A-a SJZ00_70.5 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />