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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT C"" <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON -REFUND B E ERMIT CALL (2R1 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE[ <br />JOB ADDRESSKOM Vi)CITY/ZIP o <br />u 6A CUME) <br />"CROSS STREET\tel r.'�^-Q--� }� RD APN 06�t=�L[ . E _ PARCEL SIZ/ � <br />4.7 <br />OWNER NAM E��1^1 1 �1�'6 V -t }T V C.(J PHONE .563-3113 <br />S A. 0 E FAL LLD I R -K4-0 <br />OWNER ADDRESS CITY/STATE/ZIP <br />CONTRACTORDAPkMA-SR 1 , I� PHONE 466 --q6D- GCONTRACTOR ADDRESS l Jl JLJ �L" <br />�`1 CITY/STATE/ZIP L)V45 <br />LICENSE X C-42 D C-36 OTHER A NUMBER W5 0 EXPIRATION DATE <br />It rl_ 1 <br />WATER TABLE DEPTH: 1/0 <br />- V O ft GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />❑ PERC TEST # <br />BUILDING PERMIT # <br />LAND USE APPLICATION # <br />TYPE OF WORK: <br />NEW INSTALLATION <br />REPAIR/ADDITION <br />ENGINEER DESIGNED/ALTERNATIVE <br />DISTANCE TO NEAREST WELL It FOUNDATION ,j ft PROPERTY LINE <br />1w SUMPS WIDTH ft LE GTH � 1� ft DEPTH <br />REPLACEMENT <br />OUT -OF -SERVICE SEPTIC SYSTEM <br />DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE <br />X COMMERCIAL <br />OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: <br />NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />TYPE/MFG �_J W <br />CAPACITYC2-) <br />_ gal # OF COMPARTMENTS 1 <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 ❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />`d LEACH LINES y. LEACHING CHAMBERS CO 24 # OF LINES 3 LENGTH OF LINES 44 <br />ft <br />DISTANCE TO NEAREST WELL -1064 __ ft FOUNDATION :3 0 ft PROPERTY LINE ✓+ <br />ft <br />❑ FILTER BED WIDTH ft LENGTH _ _._ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ MOUNDED WIDTH ft LENGTH ft DEPTH <br />It <br />DISTANCE TO NEAREST WELL It FOUNDATION ,j ft PROPERTY LINE <br />1w SUMPS WIDTH ft LE GTH � 1� ft DEPTH <br />ft <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION CJIJ It PROPERTY LINE t <br />ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH It DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />It <br />❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />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 />SIGNET <br />Application Accepted By <br />Final Inspection By <br />Character of Soil too Dept <br />COMMENTS71 <br />�J� ❑ SPECIAL PERMIT - <br />Soil Character: 4;l <br />PE <br />SC <br />INFO <br />Received <br />B <br />Chec <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/Code <br />Service Request # <br />Invoice # <br />Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />11 <br />r <br />