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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IVON-KEFUNDABLE PERMIT <br />GALL 209 953--7697 FOR INSPECTIONS <br />EXPIRES '1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS CID <br />y� <br />t? / i =r) � 43 <br />—CITY/ZIP <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />CROSS STREET <br />�,Q <br />ri�� <br />APN �l/V <br />� <br />' 311 ' l T <br />PARCEL SIZE <br />OWNER NAME <br />DEPTH I1cA ft <br />i <br />PHONE <br />❑ DISPOSAL PONDS WIDTH ft LENGTH ft <br />IC�f�I' D� <br />j <br />���� <br />ft PROPERTY EIRP" JOA It <br />OWNER ADDRESS %� <br />DEPTH REA ,.,IRONMENT It <br />CITY/STATE/ZIP ���� <br />ft PROPERTY LINE uzzPARTMENT ft <br />CONTRACTOR _��{ <br />I J/ , <br />S ��� ��; • <br />PHONE <br />I AM IN COMPLIANCE WITH ALL <br />CONTRACTOR ADDRESS too <br />A %L <br />CITY/STATE/ZIP <br />Y� 1� +1 �c✓�` S 34 7 <br />LICENSE C 42 C-36 <br />Ir <br />OTHER1Y7� ' �% NUMBER <br />EXPIRATION DATEarJi <br />/ <br />Sr (� •- <br />WATER TABLE DEPTH:l�� / ft GEOGRAPHICAL INFORMATION <br />7 PERC TEST # BUILDING PERMIT #� <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADI <br />Coordinates X Y <br />LAND USE APPLICATION # <br />)N ENGINEER DESIGNED <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: WIRESIDENCE ❑ COMMERCIAL aa ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: l NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY <br />CAPACITY <br />DISTANCE TO NEAREST: WELL ft FOUNDATION <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT <br />TERNATIVE <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />PO"LEACH LINES LEACHING CHAMBERS # OF LINES L <br />t <br />LENGTH OF LINES ft <br />DISTANCE TO NEAREST WELL l t14I ft FOUNDATION N! <br />ft PROPERTY LINE Iej It <br />❑ FILTER BED WIDTH ft LENGTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ MOUNDED WIDTH ft LENGTH ft <br />DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ SUMPS WIDTH ft LENGTH ft <br />DEPTH I1cA ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH ft <br />DEPTH 11 C <br />018 ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />���� <br />ft PROPERTY EIRP" JOA It <br />El SEEPAGE PITS NUMBER WIDTH It <br />DEPTH REA ,.,IRONMENT It <br />DISTANCE TO NEAREST WELL ft FOUNDATION <br />ft PROPERTY LINE uzzPARTMENT 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 LICE=NSE BOARD AND THAT <br />I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />M1N1MUM,24-H0y44QVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br />SIGNED TITLE`.p^f Vr_J-a—r <br />DATE 4 „1.4 1 <br />Application Accepted By (L <br />Final Inspection By� <br />Character of Soil to Depth of 3 Ft: <br />COMMENTS <br />Date CA4 Jf Area 1 <br />Date Ap ❑ SPE <br />Pit/Sump Soil Character: <br />Employee ID#�C�(/ <br />PERMIT - Approved by <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Che Amount <br />as Re ' ted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />`/?7 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />