Laserfiche WebLink
ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P ` <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT/ IJGALL ZU9 y53D/69/FOR INSPECTIONS LXPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS a-) coa �Uib=✓� IJY�1 (� �J•y f <br />CITY/ZIP S V-0 C- nc3 &-, Q 5 -da <br />CROSS STREET "r-1LCJ LA:C APN j l 1 I () _) � o (/ 7 PARCEL SIZE 0' 1461 <br />OWNER NAME 7�`` -' 1 gL L CPHONE <br />OWNER ADDRESS � JT iL/� SbrCITY/STATE/ZIP 4, T' BC_fLL CL ✓� Q 'L C 4 rja� <br />CONTRACTORIL A Ic1(�iA/�(6��'X c L 2 <br />'LC 1� PHONE 0 �l U l 3 qZ <br />CONTRACTOR ADDRESS Po ,JCsY t z I CITY/STATE/ZIP �� �/t L,o <br />LICENSE C-42 N C-36 OTHER NUMBER �� �t_� -1 i EXPIRATION DATE 3 V' <br />WATER TABLE DEPTH: v J ft GEOGRAPHICAL IIJFORMATION: Coordinates X Y <br />7 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 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 <br />❑ GREASE TRAP TYPE/MFG CAPACITY <br />gal # OFC PARTMENTS <br />_ _ gal # OF <br />DISTANCE TO NEAREST: WELL ft FOUNDATION <br />ft PR NE <br />ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ <br />SAND OIL SEP TEM)- <br />Code -411T <br />❑ LEACH LINES LEACHING CHAMBERS # of LINES <br />LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ FILTER BED WIDTH ft LENGTH ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ MOUNDED WIDTH _-- ft LENGTH ft <br />DEPTH <br />ft <br />�yD'CTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SUWID ft LENGTH ft <br />'Q <br />DEPTH <br />ft <br />T TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />L3DiSP DTH ft LENGTH ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />SPAAGE <br />ft PROPERTY LINE <br />ft <br />❑ PITS NUMBER WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft 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 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - <br />PLEASE CALL (209) 953-7697 <br />SIGNED '" _ _ TITLE z t)t —'�� � - <br />DATE <br />Application Accepted By A ray, <br />Final Inspection By --- <br />Character of Soil to Depth of 3 Ft: <br />COMMENTS C'L' n it <br />C 11'. <br />DEPARTMENT USE ONLY <br />Date " " " _ Area Employee ID# Wor <br />Date _ I 1 SPECIAL PERMIT - Approved by <br />Pit/Sump Soil Character: <br />PE <br />Sc <br />Received <br />Check#/ <br />Amount <br />Permit/ <br />Code -411T <br />INFO <br />B <br />Cash <br />Remitted <br />Date <br />Permit ID# <br />Service Request # <br />Jc - <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />T <br />