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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 />IVUN-KEFUNDABLE PERMIT L:ALL (ZU&) Ub3-/tiy7 FOR INSPECTIONS <br />- p —0V <br />tXPIRES 1 YEAR FROM <br />S DATE I <br />SSUE <br />JOBADDRESS 10QWDRt&iA CITY/zIP A(Vz" p <br />CROSS STREET 6V- 1rY&t Lk PN LLt(—L ) <br />— 0 V PARCEL SIZE <br />OWNER NAME 6 PHONE ty AI. "l —Dii y <br />OWNER ADDRESS 63 J�� Sr/,r'y6j 11fjW=-41*W ` I �� � / CITY/STATE/ZIP `��`[-, J i��%l�i` <br />CONTRACTOR ��Jy DEW' �L (�yJ PHONE ��� <br />CONTRACTOR ADDRESS J l '"� �L�S CITY/STATE/ZIP Geo t.G� <br />9-3tt <br />LICENSE I I C-42 11 C-36 OTHER Ci �� NUMBER 0 EXPIRATION DATE U <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION <br />❑ PERC TEST # BUILDING PERMIT # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADI <br />Coordinates X Y <br />LAND USE APPLICATION #_ <br />IN ENGINEER DES—I( <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE IJ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />Received <br />B <br />❑ GREASE TRAP TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />Date <br />DISTANCE TO NEAREST: WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ LIFT STATION SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES LEACHING CHAMBERS <br />_ # OF LINES LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ FILTER BED WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ MOUNDED WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ SUMPS WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY LI <br />ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROPERTY'59 <br />ft <br />El SEEPAGE PITS NUMBWIDTH <br />ft DEPTH l7 I '?nf. <br />SAII <br />It <br />DISTANCE TO NEAREST WELL ft <br />FOUNDATION ft PROP 18/`!" <br />ft <br />nnQ UIV <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACC R� T'a1IIT SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRE NSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPEN ANION LAWS. <br />MINIMUMANrHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-�P,L�E'A"SE CALL 209 953-7697 <br />SIGNED `�-- <br />1 r <br />TITLE VP03"-r- f A6 -f� DATE �,V 111C <br />VMY <br />E P A R T M E AL <br />T JJ SE O MLY <br />Application Accepted B Date <br />eV' Area Employee ID#� <br />Final Inspection By GM14 FkfV A'1/Lf ✓I:p_ Data <br />❑ SPECIAL PER IT - Approved by <br />Character of Soil to Depth 3 Ft: <br />P t/Sump Soil Character: <br />COMMENTS r <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />2 <br />D3 <br />-7V <br />ta5 <br />2j <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />