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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT V /* <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CA 209 953-M7 EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS -7I /_ CITY/ZIP <br />v <br />CROS STREET ///l A /feC- &0- APN /!G-j/bI/U <br />PARCEL SIZE Zf <br />OWIFiER NAME&.)I / I� �'� �C� /�-[7 h _ _ _ �J PHONE <br />OWNER ADDRESS S i/LJ• 1•q - CITY/STATE/ZIP l`. /'✓� L /i- /�3 bL' <br />V ac." L^ PHONE <br />CONTRACTOR y � % _ __ <br />CONTRACTOR ADDRESS`/mayrN�i�wV h. CITY/STATE/ZIP <br />LICENSE ❑I C-42 ❑C7C-36 OTHER NUMBER_7/— }EXPIRATION DATE___ <br />1 <br />WATER TABLE DEPTH: ;;r,,f?p ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />77 PERC TEST # BUILDING PERMIT # _ LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION i REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />rA REPLACEMENT L I OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: iftl RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: / NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />SEPTIC TANK TYPE/MFG �a CAPACITY 'V gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL v + It FOUNDATION /O • ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP , ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />iff <br />LEACH LINES <br />C LEACHING CHAMBERS <br /># OF LINES_ <br />Amount <br />LENGTH OF LINES ` ft <br />Permit/Code <br />Invoice # <br />DISTANCE To NEARES r <br />f <br />WELL <br />ft FOUNDATION _ <br />ft PROPERTY LINE ft <br />❑ <br />FILTER BED <br />WIDTH _ <br />�. ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />It FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH _- <br />_ ft LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH <br />It LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft <br />DEPTH It <br />DISTANCE TO NEAREST <br />WELL <br />ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft <br />DEPTH It <br />DISTANCE TO NEAREST <br />WELL <br />It 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 COMPENSATION LAWS. <br />IR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED <br />Application Accepted By 00 LA <br />Final Inspection Byd1 <br />Character of Soil to Depth of 3 Ft: <br />COMMENTS <br />TITLE /f [� DATE <br />DEPARTME T EONLY <br />Date_I Area Employee ID#� <br />Date 3 zoly ❑ SPECIAL PERMIT - Approved by <br />�. Pit/Sump Soil Character: <br />PE <br />SC <br />Received <br />hec <br />Amount <br />Dale <br />Permit/Code <br />Invoice # <br />Permit ID# <br />INFO <br />B <br />Cash <br />Remitted <br />Service Request # <br />Q <br />139 2 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />T <br />