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r <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />r <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT r� GALL 209 953-76,97 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS �� 7 �`Q Vj /c' .:, �L. �� c CITY/ZIP 9J��D �/ <br />CROSS STREET �� APN j O 90 (001 _5 PARCEL SIZE 0 ' ` <br />OWNER NAME 4, /'--, ;o lzo `sceov_ PHONE <br />OWNER ADDRESS 7- dp f4XPIA-0 IT STATQ <br />CONTRACTOR PHONEV <br />J 7 <br />CONTRACTOR ADDRESS _18T') CITY/STATE/ZIP <br />LICENSE 11 C-42 1-11-C-36 OTHER Cx"'Ci=�% NUMBER �l / EXPIRATION DATE�y <br />L <br />WATER TABLE DEPTH: N 5 ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION n Id tto 14 <br />INSTALLATION WILL SERVE: LL RESIDENCE Ll COMMERCIAL OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />1� <br />❑ <br />❑ <br />SEPTIC TANK <br />GREASE TRAP <br />LIFT STATION <br />TYPE/MFG 1 <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />SIZE TYPE OF PUMP <br />ft <br />CAPACITY 6 Z-© 0 gal # OF COMPARTMENTS <br />CAPACITY gal # OF COMPARTMENTS <br />FOUNDATION ft PROPERTY LINE ft <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ <br />LEACH LINES <br />LEACHING CHAMBERS <br />Code <br /># OF LINES <br />LENGTH OF LINES ft <br />Remitted <br />Dae <br />DISTANCE TO NEAREST <br />WELL <br />Permit ID# <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SUMPS <br />WIDTH <br />It <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />_ <br />ft PROPERTY LINE 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 COMPENSATION LAWS. <br />Ivitiviivluivl Z+I17uu fiuvAIVL.c /vV I IL.c P1cwwriCu ruti I/VJrCL.I IL/IVJ - r-LCHJC L.HLL- <br />SIGNED TITLE�++i�r G DATE <br />vL,v K`ver I, DEPARTMENT USE ONLY�.) <br />Application Accepted By ►'V Date a Area lqq Employee ID# <br />Final Inspection By Date //10 ❑ SPECIAL PERMIT - Approved by <br />Character of Soil to Depth of 3 Ft:Pit/Sump Soil Character: <br />COMMENTS S�(Q (pl't,h C0004 -70 5(i <br />PE <br />Sc <br />ReceivK <br />Check#/ <br />Amount <br />Permit/ <br />Code <br />INFO <br />Cash <br />Remitted <br />Dae <br />Service Request # <br />Invoice # <br />Permit ID# <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />