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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 />NON-REFUNDABLE PERMIT <br />A CALL 209 53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE[ <br />JOB ADDRESS <br />Received <br />B <br />r� <br />CITY/ZIP �' "! <br />3 <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />/� <br />2 <br />�J �70 <br />1iJ <br />CROSS STREET <br />v <br />APN �7 <br />PARCGELSIZE <br />OWNER NAME <br />//cc <br />UJ b,, <br />u - ' ✓�1- - PHONE <br />r / <br />! "' .� y�J 7 <br />OWNERADDflESS <br />� <br />7 S. <br />p qq <br />4AJ CITY/STATE/ZIP <br />JJ73L <br />J�(1 <br />CONTRACTOR <br />Y , 4) a/ 30"- L <br />ka PHONE �® %f ✓�� <br />7l �� Cs' <br />CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />ft <br />LICENSE Il C-42 <br />❑ C-36 OTHER <br />NUMBER EXPIRATION DATE <br />ft <br />❑ MOUNDED WIDTH ft LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />WATER TABLE DEPTH: /y (f V ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PE <br />Code <br />❑ PERC TEST # BUILDING PERMIT # — 77 LAND USE APPLICATION # <br />Received <br />B <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br />Amount <br />emitted Date <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />Invoice # <br />INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL OTHER <br />2 3 <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />lop <br />SS cop,IS <br />SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS v <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PK:G TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST WELL 0 ft FOUNDATION 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 />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ SUMPS WIDTH ft LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br />ft <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 COMPEN ON LAWS. <br />MINI HOUR ADVAN TICE REQUIRED FOR INSP CTI NS - PLEASE CALL 209 953-7697 <br />SIGNE TITLE GALE !y�1�. DATE <br />� T <br />MAI <br />T <br />0, <br />Q <br />NT <br />IN <br />Nr <br />DEPARTMENT LA.E QfNbY <br />Application Accepted By Date Area Employee ID <br />Final Inspection By �'tti Date t ❑ SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: �� '- Pit/Sump Soil Character: <br />COMMENTS <br />42-01 [, 7 7 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />r <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />emitted Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />2 3 <br />�— <br />SS cop,IS <br />(-0034-1`/C3 <br />42-01 [, 7 7 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />r <br />