Laserfiche WebLink
ONSITE WASTEWATER TREATMENT SYSTEM PERMIT X " <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT `' e GALL (209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE <br />w <br />JOB ADDRESS O ;1,,-0A CITY/ZIP -7"Ae-41 <br />QROSS STREET �� C r U Y APN 1; "0400S PARCEL SIZE ()• <br />6WNER NAME G� I lOncrK ' 1 S 7-r PHONE <br />`OWNER ADDRESSlS a ►+� e l CITY/STATE/ZIP <br />CONTRACTOR PA/�/� L �2t� o]Qn PHONE ��M% T — y r3 I <br />CONTRACTOR ADDRESS t!/Gi Y .?Ce -AJ L/► C -( CITY/STATE/ZIP / �d <br />LICENSE I I C-42 I C-36 OTHER A NUMBER �� i �/S _� EXPIRATION DATE�� <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />11 PERC TEST # BUILDING PERMIT # ___. LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION e REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE I COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />❑ GREASE TRAP <br />❑ LIFT STATION <br />TYPE/MFG <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />SIZE TYPE OF PUMP <br />CAPACITY gal # OF COMPARTMENTS <br />CAPACITY gal # OF COMPARTMENTS <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES <br />ft <br />Date <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />y <br />ft PROPERTY LINE J ' <br />ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />' , ft <br />DEPTH / *P <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE J <br />ft <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />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 COMPENSION LAWS. <br />MINIMUMIaHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -/ .PLEASE CALL (209) 953-7697 Q <br />SIGNED fes-- TITLE ` -Iken DATE <br />Application Accepted By <br />Final Inspection By <br />Character of Soil to Dept <br />COMMENTS T <br />DEPARTMENT USE O_NL Y <br />Date - Area G Employee ID# <br />Date E SPECIAL PERMIT - Approved by <br />3 F : / Pit/Sump Soil Character: <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B V <br />Check#/ <br />I Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />11 <br />1 H 06-1 <br />�" <br />S P-6079�/ <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />V, <br />