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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 v CALL 209 953-7697 FOR INSPECTIONS <br />A EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS Z0��S• F- _ __.CrrY/ZIP/ V R A V e <br />CROSS STREET L S'1�C- ! w�� APPJ 7,01 Z' 90-34 PARCEL SIZE <br />OWNER NAME�`, a�^r 1�`� ✓. PHONEE�/� <br />OWNER ADDRESS I 1W �f�I CITY/STATE/ZIP <br />CONTRACTOR Ow A+V- PHONE <br />CONTRACTOR ADDRESS <br />LICENSE L_I C-42 ❑ C-36 OTHER <br />CITY/STATE/ZIP <br />NUMBER EXPIRATION <br />WATER TABLE DEPTH: V QU ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # BUILDING PERMIT LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION EPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL 11OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />SEPTIC TANK <br />❑ GREASE TRAP <br />❑ LIFT STATION <br />TYPE/MFG T� V <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />SIZE TYPE OF PUMP <br />CAPACITY / UQy 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 />/ <br />LEACH LINES i LEACHING CHAMBERS <br />,✓��/ <br /># OF LINES LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST <br />WELL 1 b b It <br />FOUNDATION C7 ft PROPERTY LINE ' <br />ft <br />❑ FILTER BED WIDTH <br />ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ MOUNDED WIDTH <br />ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ SUMPS WIDTH <br />ft LENGTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft DEPTH <br />ft <br />/ DISTANCE TO NEAR ST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE <br />ft <br />��J^(1\, SEEPAGE PITS NLr4SER <br />WIDTH <br />Ifaff ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />� <br />WELL ft <br />r <br />FOUNDATION 1 �� ft PROPERTY LINE <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND <br />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 COMPENSATION LAWS. <br />SIGNED <br />DATE <br />PARTMENTIL)Sif ONLY <br />Application Accepted By Da Area Employee ID# <br />Final Inspection By Date 2l SPECIAL ERMIT - Approved by <br />Character of Soil to Depth of 3 Ft: it/Sump Soil Character: <br />COMMENTS <br />PE <br />SC <br />Received <br />Check#/ <br />Amount <br />Date <br />Permit/ <br />Invoice # <br />Permit ID# <br />e <br />INFO <br />B <br />Cash <br />Rem'tted <br />Service Request # <br />ID <br />4IL <br />!s <br />? <br />37 <br />% <br />cc"r' <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 '5J '1/ <br />