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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAOUIN':OUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLERMIT CALL 20 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS �%J C_CITY/ZIP <br />CROSS STREET C.• APNJ (� [ P RCEL SIZE O. <br />OWNER NAME 0 PHONE <br />OWNERADDRESS CITY/STATE/ZIPCONTRACTOR y %/l/V%�/ /r�K1�/ �'' PHONE�'�- <br />CONTRACTOR ADDRESS CITY/STATE/ZIP j <br />LICENSE I I C-42 C-36 OTHER NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: <br />LI PERC TEST # <br />TYPE OF WORK: <br />t 1 ft GEOGRAPHICAL INFORMATI Coordinates X Y <br />BUILDING PERMIT # —jgof tk6l LAND USE APPLICATION # <br />NEW INSTALLATION R AIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: ESIDENCE <br />[-.I COMMERCIAL <br />❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />SEPTIC TANK <br />TYPE/MFG <br />/� <br />CAPACITY � i�Z gal # OF COMPARTMENTS A7-- <br />❑ GREASE TRAP <br />TYPE/MFG <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES'_ <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ FILTER BED <br />WIDTH ft LENGTH <br />ft <br />DEPTH _ ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />It PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft <br />DEPTH ft <br />SEEPAGE PITS <br />DISTANCE TO NEAREST WELL ft F91NDATION <br />NUMBER --f? WIH 7 ft <br />ft PROPERTY LINE ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL i <br />ft FOUNDATION <br />ft PROPERTY LINE 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 COMPENS TION LAWS. <br />MINI Mtn HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED jy/ ``� ✓ TITLE DATE —10'/ <br />Application Accepted <br />Final Inspection By_ <br />Character of Soil to D <br />COMMENTS <br />DEPARTMENT U E O LN"`�N41 % <br />Date a Area E m p I jofai;6 <br />Date �I a ❑ SPECIAL PE MIT - Approved by <br />of 3114 . Pit/Sump Soil Character: <br />PE <br />Code <br />Sc <br />INFO <br />Received <br />ck#/ <br />Amount <br />Remi ed <br />Date <br />Permit <br />Service Request # <br />Invoice # <br />Permit ID# <br />rq�Cash <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />