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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P — ' <br />S. -.N JOAQUINy OUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NONREFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS � � J C)CITY/ZIPzC <br />CROSS STREET !�� v_ APN LI , I 2-;26;q PARCEL SIZE <br />OWNER NAME CL / '�►1(_ Z L V� yA�, n�!� /PHONE �/© i -_/�l 3/- J <br />OWNER ADDRESS / ( " �!l�C�{^, � 11 y v CITY/STATE/ZIP � J�ack( ,q5� <br />CONTRACTOR PHONE <br />CONTRACTOR ADDRESS CITY/ TE/ZIITPP HT <br />LICENSE C-42 I C-36 OTHER NUMBER - EXPIREItki}176 �� 1 ''n <br />WATER TABLE DEPTH: "\j ft GEOGRAPHICAL INFORMATIO14: Coordinates X Y <br />I PERC TEST # BUILDING PERMIT # _ ._ LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br />❑ <br />SEPTIC TANK <br />TYPE/MFG <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />CAPACITY <br />IPIW3 <br />i # <br />gal # OF COMPARTMENTS <br />it ID# <br />❑ <br />GREASE TRAP <br />TYPE/MFG <br />i9?5�07g1;Z7 <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <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 />❑ <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 />❑ <br />SUMPS <br />WIDTH <br />ft <br />LENGTH <br />It <br />DEPTH <br />ft <br />EAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />DISPO <br />I <br />ft <br />LENGTH <br />ft <br />DEPTH <br />ft <br />EST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />El <br />SEEPAGE <br />WIDTH <br />ft DEPTH <br />ft <br />DATANC EST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />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 HOUR ADVA NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 20 <br />SIGNED Z TITLEy t f DATE <br />Application Accepted By ✓ ' "` <br />Final Inspection By <br />Character of Soil to Depth of 3 Ft:_ <br />COMMENTS ' <br />gGIrelIv, <br />C c, <br />I IVI C IV 1 UJC VIYL I <br />Date " I " / y Area e1 1 Employee I D# un <br />Date - I SPECIAL PERMIT - Approved by <br />Pit/Sump Soil Character: <br />�dn /1 t-, 9 JI b&' --S �V <br />PE <br />SC <br />INFO <br />Received <br />By <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/Code <br />Service Request # <br />IPIW3 <br />i # <br />it ID# <br />i9?5�07g1;Z7 <br />__E-z%jxr_1tV <br />Ij <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />U. <br />M <br />Y <br />0 <br />z <br />