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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-KEFUND BIS E MJ <br />JOB ADDRESS <br />CROSS STREET kin 011A <br />c <br />OWNER NAM[ - -5-m <br />F� <br />OWNER ADDRESS <br />CONTRACTORf�%�l <br />CONTRACTOR ADDRESSIA1 l 1 J <br />LICENSE kC-42 ❑ C-36 OTHER <br />k <br />953-7697 FOR INSPECTION EXPIRES 1 YEAR FROM UA ISSUED <br />A P N VvI t21� J ! /-7 U PARCEL SIZE I e Z <br />PHONE <br />lioA � A' CITY/STATE/ZIPy J \ J C PHONE <br />1 CITY/STATE/ZIP <br />NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: / �D ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />11 PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGN �[ip�I <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIALy L1OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 NUMBER OF EMPLdkWS;— _ # 4U18 <br />❑ SEPTIC TANK <br />❑ GREASE TRAP <br />❑ LIFT STATION <br />TYPE/MFG L'm � cr <br />TYPE/MFG <br />DISTANCETO NEAREST: WELL <br />SIZE TYPE OF PUMP <br />ft <br />CAPACITY gal # OF COMPWLV9vlN <br />CAPACITY gal # OF COMPARTMENTS_ PARTMPr- <br />-DISTANCE <br />FOUNDATION ft PROPERTY LINE ft <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />I LEACH LINES <br />LEACHING CHAMBERS # OF LINES�'j <br />LENGTH OF LINES �j <br />ft <br />Permit ID# <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />1 <br />ft PROPERTY LINE LO <br />ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />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 <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE To NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ` <br />ft <br />SEEPAGE PITS <br />NUMBER <br />!?—:WID H <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL <br />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 COMPENS.AIION LAWS. <br />DATE C i <br />COMMENTS <br />Date f % ir ' %ieJP ❑ SPECIAL PERMIT - Approved by <br />Pit/Sump Soil Character: <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Ch ck#/ <br />ash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />1 <br />6& <br />-24'-:S <br />S Q <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />