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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> r S AN 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 /> iJOB ADDRESS S �i4GD/\I �SL/�T/L� /?O� ,7 CITY/ZIP /6G G fp/lJ / Sze <br /> CROSS STREET /9L DAV ZS/i .*V D APN �G l OS6 l v PARCEL SIZE 2,- d <br /> n } �` W o <br /> OWNER NAME �G C/��7J��0�V �D/S T,�le— 2 JPCc� PHONE <br /> OWNER ADDRESS 3y�i �� /4//�I-5 T/L/J���Z !�Y S_ CITY/STATE/ZIP �j7O/J�U�TGdn�Iy <br /> CONTRACTOR / G/ —LN/G PHONE Z o ! Gam^/�/' �O / <br /> CONTRACTOR ADDRESS <br /> �O ��� ��7 CITY/STATE/ZIP <br /> LICENSE C-42 C-36 OTHER G`/ NUMBER 7w 2A5�5 EXPIRATION DATE <br /> WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> I <br /> PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESI ED/ALTERNATIVE <br /> REPLACEMENT I I 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 #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It 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 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ly8n l P )`t <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH /"__ di:, t <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH SS� c�:9`'J ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY ft <br /> Ll <br /> ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH �CEpAft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE YF�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 /> MINIMUM 48 H Uig ADVANCE NOTICE REQUIRED FOR INSPECTIONS-P ASE CALL 209 953-7,697, <br /> SIGNED TITLE �F�T� .e�G�l//LDATE %/ <br /> v <br /> r <br /> EPA RTMENT S 17 ONLY <br /> i <br /> Application Acceptedy Date Area 'Z Employee ID# <br /> Final Inspection By Date S /I Z /La F' SPECIAL PERMIT- pproved by <br /> Character of Soil to Depth of 3 t: Pit/Sump Soil Character: Q <br /> COMMENTS 1'-S-P 133v) r il&Ly J ,VULt'L_ �, U 6 i iti'l)5 i P)"'1"1) �C <br /> PE SC Received Check#/ Amount Permit/Code INFO B sh Remitted Date Service Request# Invoice# Permit ID# <br /> ZQW0 <br /> 42-01 (J 59 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 5/5/17 <br />