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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON -REFUND BL RMIT CALL 09 953-7697 FOR INSPECTIONS ExPPIR,ES 1 YEAR FROM DATE ISSUED <br />Pi 1 01 <br />JOB ADDRESS I <br />r CITY/ZI ,v <br />CROSS STREE '�J 07 %5Lu APN % y - 100 PARCEL SIZE 5 <br />177 -AC 3 <br />OWNER NAME ' `K) W OV^M • PHONE t 544 )56 <br />-qa <br />A <br />OWNER ADDRESS 4 AN 1 ADI�%�/�•ci • r CITY/STATE/ZIPAOTaCq5337 <br />CONTRACTOR �. - `PA�'� !6 b� L, .'GbK-qS INC—PHONE 4-66-1:1607 <br />CONTRACTOR ADDRESS <br />LICENSE lA C-42 ❑ 1 C-36 OTHER <br />NUMBER 100511 ✓_EXPIRATION <br />WATER TABLE DEPTH: rl V V 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 />)C REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE I 1 COMMERCI ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />)1 <br />✓ L <br />12,03 <br />Check <br />ash <br />SEPTIC TANK TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS_ L <br />❑ <br />GREASE TRAP TYPE/MFG <br />CAPACITY gal # OF COMPARTMENTS <br />O <br />I <br />O -E <br />DISTANCE TO NEAREST: WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />LIFT STATION SIZE TYPE OF PUMP <br />❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />1 <br />_ ... <br />LEACH LINES r LEACHING CHAMBERS ek <br />.__.. _ ._.... ___.... <br /># OF LINESLENGTH OF LINES ft <br />� <br />DISTANCE TO NEAREST WELL © <br />ft FOUNDATION O ft PROPERTY LINE 2_40 ft <br />❑ <br />FILTER BED WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />MOUNDED WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SUMPS WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION ft PROPERTY LINE ft <br />❑ <br />DISPOSAL PONDS WIDTH ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST WELL <br />It FOUNDATION ft PROPERTY LINE ft <br />❑ <br />SEEPAGE PITS NUMBER WIDTH <br />ft DEPTH ft <br />DISTANCE To NEAREST WELL <br />ft FOUNDATION 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 <br />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 COMPEN$A_TION LAWS. <br />I OUR A RC REQUIRED FOR I TIO S- PLEASE CALL 209 9W -76q7 <br />SIGNED <br />QUILTITLE <br />DATE 1 <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS <br />- Approved by <br />PE <br />SC <br />INFO <br />Received <br />B <br />Check <br />ash <br />Amount Date <br />emitted <br />PePermit/Code <br />rvice Request # <br />Invoice # <br />Permit ID# <br />u�> <br />* o ?3 <br />3 <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />