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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 <br />CALL 209 953-7597 FOR INSPECTIONS EXPIRES 1 YEAR FROM UATE ISSUE[ <br />JOB ADDRESS <br />CITY/ZIP <br />CROSS STREET <br />/ <br />APN 1 ���0 �V T PARCEL SIZE <br />^w <br />OWNER NAME ��f Nt Lu <br />f PHON�20 qJ S 9-f - t+-5 <br />�/% <br />OWNER ADDRESS Tj ��4&5 <br />/� J/ ' <br />L C I �/ —CITY/STATE/ZIP 1-- i zz'/ <br />CONTRACTOR k—Ae <br />PHONE _ <br />CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE C-42 C-36 OTHER <br />NUMBER EXPIRATION DATE <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 DESIG ED/ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM -DESTRUCTION <br />INSTALLATION WILL SERVE: 1 RESIDENCE ❑ COMMERCIAL I 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 />CAPACITY <br />CAPACITY <br />ft FOUNDATION <br />❑ PKG TX PLANT <br />❑ LEACH LINE ❑ LEACHING CHAMBERS # OF LINES <br />NCE TO NEAREST WELL ft FOUNDATION <br />❑ FILTER' DTH _ ft LENGTH <br />(STANCE TO NEAREST WELL ft FOUNDATION <br />❑ WIDTH ft LENGTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />❑ SU WIDTH It LENGTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />❑ SEEPAGE PITS NUMBER _ WIDTH <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARAT�( t�LOSED SYSTEM) <br />LENGTH OI�N ' ft <br />It PROPERTY LI!4ft <br />ft DEPTH ft <br />It PROPERTY LINE ft <br />ft DEPTH JOA P A,ft <br />ft PROPERTY L ft <br />ft DEPTH ft <br />ft PROPERTYt, I ft <br />ft DEPTH SAAB, ft <br />QUlRFLEIPJ <br />ft ft DEPTH RO ft <br />TH DLF . ?'Al ft <br />ft PROPERTY I INE SENT ft <br />I HEREBY CERTIFY THAT 1 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 />�cM/INIMUM 48HOURADV, <br />SIGNED h, .J o -K -k al -c <br />Application Accepted By <br />Final Inspection By_ <br />Character of Soil to.Deptl <br />COMMENTS /7& <br />of 3 <br />ARTME <br />Date; <br />Date <br />TIONS - <br />I S-EIONL Y <br />Area <br />SPECIAL PERMIT <br />Pit/Sump Soil Character: <br />DAT&Z. <br />Employee ID# <br />Approved by <br />PE <br />Code <br />Sc <br />INFO <br />Received <br />B <br />Check#/ <br />ash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />it ID# <br />;z <br />i-5 <br />G <br />1 <br />9z o � w <br />42-01 (J !J Ji-� ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />