SR0078595 - Laserfiche WebLink

Home Browse Search

ONSITE WASTEWATER TREATMENT SYSTEM PERMIT f / SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT �.- CALL 209 953-7697 FOR INSPECTIONS ! EXPIRES 1 YEAR FROM DATE ISSUED J JOB ADDRESS /I D /—/ O% m Q i, 4 ✓e– CITY/ZIP a t0 kG!�l ROSS STREET le kAPN �O 3 �f0� Z _ PARCELSIZE OWNER NAME /// a ✓ CO Q G /� C O _ _ PHONE g A OWNER ADDRESS � /r y �' /��G�� Q � � ��_CITY/STATE/ZIP /aL/ (:ONTRACTOR I a JJ �7��/ �✓a PHONE LD / -O �O `a3 /2 / CONTRACTOR ADDRESS / O / '`� p_ / CITY/STATE/ZIP i[Je44 /1" 1 Ciw -i< LICENSE Ila' C:-42 ❑OC -36 OTHER NUMBER le79 -? � EXPIRATION DATE_ ✓�J / WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y L] PERC TEST # BUILDING PERMIT # O L7 LAND USE APPLICATION # TYPE OF WORK: V NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE lI COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: d NUMBER OF BEDROOMS: Pr / NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG / CAPACITY �6 OO gal # OF COMPARTMENTS Z ❑ GREASE TRAP TYPE/MFG _ _ CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION 7 _ ft PROPERTY LINE Z� ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS DISTANCE TO NEAREST WELL I ` ft _ # OF LINES 3 LENGTH OF LINES �% ft FOUNDATION J-0 ` ft PROPERTY LINE LSI ft ❑ FILTER BED WIDTH ft LENGTH Chec ash Amount Remitted ft DEPTH ft Invoice # DISTANCE TO NEAREST WELL ft FOUNDATION 2� ft PROPERTY LINE _ It ❑ MOUNDED WIDTH ft LENGTH ft DEPTH w_ wA6-t DISTANCE TO NEAREST WELL _ ft FOUNDATION ft PROPERTY LINE t �t ❑ SUMPS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH 1 ft / DISTANCE TO NEAREST WELL ft/FOUNDATION ft PROPERTY LIIAFt.IR�NMc.�VN71R ENV2/"SEEPAGE 3 �� EPARTM�.�, IN SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ---Z i S ft FOUNDATION S ft PROPERTY LINE Zw� ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. SIGNED __ -TITLE ©'r/�`r/!'%J�r�y�r DATE DEPARTMENT USE ONLY _ Application Accepted By Date I _ Area _� Employee ID#, • wo Final Inspection By_ �e i" DateI I SPECIAL PERMIT -Approved by Character of Soil to Depth/of 3 Ft: _ /_ c3'` Pit/Sump Soil Character: COMMENTS�v� a 14 L4~ /eco -- PE Code SC INFOE Received B Chec ash Amount Remitted ate Permit/ Service Request # Invoice # Permit ID# X11. l I 2� PQ n 1YYllf SKD679 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17