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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P f
<br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 952DS - (209) 468$420
<br />NON-REFUNDABLE PERMIT eq �++ CALL 209p953-7697 FOR INSPECTIONS j� EXPIRES 1 YEAR FROM DATE ISSUE[
<br />JOB ADDRESS �i 4 -.L-1-: ...___.__ i- V YJ-------ff-�..._-_-___CITY'"l_LP¢ > ! I _Itln _XVI
<br />CROSS STREET Li - Ir 59°- _ ? _._.. APN �1. '- �,,,,a ;,,,�PAARCEL SIZE �) .
<br />OWNER NAMEk%X,�'4�4t✓w�3✓1._4_C.-yiJ `�._.[F...Y.. PHONE ..,7,� 1 - G`[ I
<br />OWNER ADDRESS ,.y0' i:tG'C�w� t"°r±__,�{,L!+'� �17Y/STATEIGIP!'#ry` '.]lQ,4_j .,/�
<br />CONTRACTOR,"_,.�,.;..�bW__%S.______._. ' .r:r #C Is -C.., S,� it PHONE 1.� `, , 1 5 3,) - -
<br />CONTRACTOR ADDRESS % CnY/STATE/ZIP _-, eT - C 3-
<br />LICENSE ❑'._ C-42 01 C-36 OTHER NUMBERyj� -EXPIRATION DATE.- AOL —
<br />I
<br />WATER TABLE DEPTH: ft _ _ h GEOGRAPHICAL INFORMATION: Coordinates X Y
<br />L,' PERC TEST # BUILDING PERMIT #._..., j.?,a..:LVeD'i NO 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: ESIDENCE COMMERCIA L. OTHER
<br />NUMBER OF LIVING UNITS; NUMBER OF BEDROOMS; ,,,
<br />,,,, ,,,,,,,,,,,_,,,,_.,_.____ NUMBER OF EMPLOYEES:
<br />❑ SEPTIC TANK TYPE/MFG tst� —! 7,,0Q___ CAPACITY "","_ _.__ gal # OF COMPARTMENTS
<br />❑ GREASE TRAP TYPE/MFG _,....... ----- - CAPACITY _ ,_ gal #OF COMPARTMENTS ____
<br />DISTANCE TO NEAREST: WELL N FOUNDATION ___ It PROPERTY LINE it
<br />❑ LIFT STATION SIZE �..__.,.__..... TYPE OF PUMP____ _ _ ______., ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM)
<br />❑ LEACH LINES LEACHING CHAMBERS
<br />I ..___..... __..... .... # OF LINES . LENGTH OF LINES it
<br />DISTANCE TO NEAREST WELL
<br />NE ft
<br />It F(HUNOATION It PROPERTY LINE
<br />"GTr FILTER BED WIDTH ft LENGTH __to
<br />j,.,,,_,_.�;1D.__:._ . _R DEPTH .�iS it
<br />_, ,a,_.__,�
<br />DISTANCE TO NEAREST WELL
<br />_,,,....._ It FOUNDATION �- _ft PROPERTY LINE,,,...I.it
<br />❑ MOUNDED WIDTH __ it LENGTH v
<br />_ _ft DEPTH it
<br />DISTANCE TO NEAREST WELL _____..... ... _...........
<br />, it FOUNDATION fl PROPERTY UNE it
<br />❑ SUMPS WIDTH ...._.._ .. it LENGTH .. ...........
<br />......... ..._...... __............. _..... .—ft DEPTH _ it
<br />DISTANCE TO NEAREST WELL .__.,........
<br />ft FOUNDATION __. ft PROPERTY LINE it
<br />❑ DISPOSAL PONDS WIDTH .................... It LENGTH _ ..........
<br />_....._...._............__._..._____ ft DEPTH _.. 0I
<br />_.._
<br />DISTANCE TO NEAREST WELL -__,_,.
<br />it FOUNDATION _.._..._.._... _................ ft PROPERTY LINE 116
<br />❑ SEEPAGE PITS NUMBER...__ WIDTHv�_......_..__._.
<br />www
<br />Ulp
<br />tt DEPTH
<br />DISTANCE TO NEAREST WELL
<br />rw Ci�
<br />It FOUNDATION ft PROPERTY LINE.,
<br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDAkc ITIL $� w
<br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES
<br />AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE
<br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS
<br />STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH All
<br />WORKERS COMPENSATION LAWS.
<br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 009A 953-76 77
<br />SIGNED ---__._..._....__. _
<br />............. TITLES.e=_21 ��i, _... _.._............ ___ DATE,
<br />yucrgn/m:
<br />Application Accepted B ___ 1 Date.
<br />Final Inspection By "_....._ _._. Date
<br />Character of Soil to Da f __._ __.... ...
<br />COMMENTS
<br />0Zia'
<br />:u p`
<br />6e fir[ rr 151 1
<br />Lh�rs Ltr,.r� oL eL S Yep. YCDt»
<br />1S jFJO ,..-j
<br />Area t T�7 Employee IDL(
<br />I.'. SPEC IAL PERMIT -Approved by
<br />Pit/Sump Soil Character:
<br />PE
<br />Code
<br />SC Received Check#/ Amount
<br />INFO B Cash Re
<br />Date
<br />PermW Invoice # Permit ID*
<br />Service Request .#
<br />21
<br />t I b.
<br />'3 4 00-73a3-7 _
<br />42.01
<br />5/5117
<br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT
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