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ONSITE WASTEWATER `rHEATMENT SYSTEM PERMIT <br />SAN 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 />JOB ADDRESS <br />CITY21P <br />CROSS STREET`- �y, ��___ APN 141'l 00 � PARCEL SIZE I �jll <br />OWNER NAME_ 1AA i Atak �\ 1"� _ _ _ PHHONE 2N , ' V <br />OWNER ADDRESS /'� �C lJ / � f C� _ CITY/STATE/ZIP � �\�CA O�C5-- <br />CONTRACTOR PHONE <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE I C-42 1 C-36 OTHER _ NUMBER EXPIRATION DATE ____ <br />WATER TABLE DEPTH: BUILDING <br />GEOGRAPHICAL INFORMATION: Coordinates X _ Y <br />PERC TEST # PERMIT #_ LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/Atmi]ION i ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT OUT-OF-SEHVICE SEPTIC SYSTEM ❑ DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE COMMERCIAL ❑ OTHER <br />Ni imprn nF I mKir. I INITR• NuMRFR OF RFnROOMS: _ NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG CA4811 gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG _ gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WLI_I_ ft FO ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP _ _ ❑ PKG TX PLANT D OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />D LEACHING CHAMBERS <br />Received <br />ec <br /># OF LINES <br />Date <br />LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />Code <br />ft <br />FOUNDATION <br />ash <br />_ ft PROPERTY LINE <br />ft <br />❑ FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST- <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE_ <br />ft <br />❑ SUMPS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />_ft PROPERTY LINE <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH WACUR <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE I-Ep <br />ft <br />❑ SEEPAGE PITS <br />NUMBER <br />_ <br />WIDTH <br />ft DEPTH SCA, ._ O�[7 <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />_ ft <br />FOUNDATION <br />ft PROPERTY I.j�IEENIir'QV/N CA, <br />It <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCEP�/t'P{�!I <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENS S <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />Application Accepted By _6-4 <br />Final Inspection By <br />Character of Soil to Depth of 3 Ft: <br />COMMENTS ��nfrc T <br />a <br />RED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE e&_)/7 &,V _. DATE dj: /9 <br />Date <br />Date <br />Area 4 <br />❑ SPE <br />Pit/Sump Soil Character: <br />SKI /U Employee ID# <br />AL PERMIT - Approved by <br />PE <br />SC <br />Received <br />ec <br />Amount <br />Date <br />Permit/ <br />PERMIT <br />mit ID# <br />Code <br />INFOB <br />ash <br />Remitted <br />Service Request # <br />C� <br />42-01 �u Oma- (�(/ LiC/ ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />ec� f �Z, CSa <br />r2 <br />