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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (ZUy) Yb3-/65/ FOR INSPECTIONS t=XPIRES 1 YEAR FROM DATE ISSUE( <br />_ � J <br />JOB ADDRESS%u �. �Q(ir� 1rAin�,n.'r, / s CITY/ZIP (c�) �77� <br />CROSS STREET wake G -F, 2 CI APN '+ c.,v PARCEL SIZE �v <br />i <br />--OWNER NAME I �P^% c _ ` 0 ` � , �_ I` I PHONE f �{1�Jy <br />OWNER ADDRESS % t I� 1 q ' "�y ` CITY/STATE/ZIP 2� �'Q {+ <br />CONTRACTOR l C-- •i `7 Fri PHONE / I �'� � �rt 0,(—q-2 <br />C�ONTRACTORADDRESS i����%_ 1iiL(t_) �L('C. h'ti-' �j CITY/STATE/ZIP � 77 <br />LICENSE C-42 C 36 OTHER I (i� % I �7 •f NUMBER O�j�s (�� EXPIRATION DATE <br />d <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ❑ ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM 5-z' DESTRUCTION tC - <br />INSTALLATION WILL SERVE: I RESIDENCE 1 1 COMMERCIAL OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />DISTANCE To NEAREST: WELL <br />❑ LIFT STATION SIZE TYPE OF PUMP <br />❑ LEACH LINES LEACHING CHAMBERS <br />DISTANCE TO NEAREST <br />WELL <br />Received <br />❑ FILTER BED WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />Code <br />❑ MOUNDED WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />a est # <br />I <br />❑ SUMPS WIDTH <br />ft <br />LENGTH <br />DISTANCE TO NEAREST <br />WELL <br />❑ DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />(STANCE TO NEAREST <br />WELL <br />LJ SEEPAGE PI UMBER <br />WIDTH _ <br />DA&1%CE To NEAREST <br />WELL <br />I HI <br />JOA <br />CUR <br />WORT <br />SIGNED <br />CAPACITY <br />CAPACITY <br />ft FOUNDATION <br />_ ❑ PKG TX PLANT <br /># OF LINES <br />ft FOUNDATION <br />ft FOUNDATION <br />ft FOUNDATION <br />ft FOUNDATION <br />ft FOUNDATION <br />ft FOUNDATION <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LENGTH OL LINES ft <br />ft PROft <br />ft DEPTH Y hr ft <br />ft PROPERTY LINE ft ft <br />ft DEPTH ft <br />ft PROPERTY LINE ft <br />ft DEPTH It <br />ft PROPERTY LINE 0 �,ft <br />e <br />ft DEPTH `"'xN It <br />ft PROP LROn/ ,. UIy„_ It <br />ft DEPTH OFpq'•R> � It <br />ft PROPERTY LINE F� ft <br />PtJW I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />kv#MINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />1 TIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />ENSATION LAWS. <br />48 <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to Depth of 3 <br />COMMENTS TE i u 0 , <br />- PLEASE CALL (209)953-7697 <br />ABATE <br />EPARTMENT USE O Y ,� l `'� <br />Date ' �% Area / 1 Employee ID#�' <br />Date / I I SPECIAL PERMIT - Approved by <br />Pit/Sump Soil Character: <br />PE <br />SC <br />Received <br />Check#/ <br />Amount <br />Date <br />Permit/Permit <br />ID# <br />Code <br />INFO <br />B <br />ash <br />RemittedServic <br />a est # <br />I <br />01*4 1 <br />42-01 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />77- <br />