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a-3a-15s <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUtN 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 �� CITY0P�y C <br /> CROSS STREET -APN Iq 0 PARCEL SIZE_1.141. > <br /> v <br /> v <br /> OWNER NAME on r esge e► M <br /> PHONE <br /> OWNER ADDRESS I �� �[� I 1 rGt 4&V) ITYISTATEIZIP p <br /> CONTRACTOR- t �3 6•g4iC h AnG i PHONE <br /> CONTRACTOR ADDRESS r: &G.r.% _CITYISTATEIZIP � �a <br /> LICENSE C-42 C-36 OTHER NUMBE4 f 1 557 EXPIRATION DATE <br /> r <br /> WATER TABLE DEPTH:_ s fV ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> 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: +�+ SIDENCE I COMMERCIAL L1 OTHER <br /> NUMBER OF LIVING UNITS: ! _ NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> Ul- SEPTIC TANK TYPE/MFG 1��'7--' CAPACITY I>Flp-. gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/fMFG CAPACITY 1 gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL _�.6n, It FOUNDATION ft PROPERTY LINE , ft <br /> ❑ LIFT STATION S1ZE TYPE OF PUMP __ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ......... ....__ _... ........ ........ ... ... .......... ........_ <br /> LEACH LINES LEACHING CHAMBERS #OF LINES r- LENGTH OF LINES [5d It <br /> DISTANCE TO NEAREST WELL—I C It FOUNDATION._ID+ ft PROPERTY LINE .�y ft <br /> ❑ FILTER BED WIDTH It LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE _ _ ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN ft <br /> ❑ SUMPS WIDTH ft LENGTH It DEPTH C►�r�,�._ ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH 7A�� ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPER74IM90A �_ ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ? %ON ouATi rr ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION II PROPERTY LINE LcA.414r■.__ ft <br /> l 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 COMPEN�gTfON LAWS. <br /> MINIMUM ��jj R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 <br /> SIGNED TITLE + �` DATE 3 <br /> 40 <br /> a <br /> l+ <br /> DEPARTMENT SE ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Final Inspection By 1pt& Date? ❑ SPE tAL ERMIT-Approved 6y <br /> Character of Soil to Depth of 3 Ft: PWSump Soil Character: <br /> COMMENTS _ <br /> PE SC Received heck Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B Remitted Service Re uest# <br /> SAO <br /> 42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 515117 <br />