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I 4 <br />ONSITE WASTEWATER TREATMENT SYSTEM PERMIT 'x <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IVUN-KEFUNDABLE PERMIT ss CALL ZUJ `Jb3-lb•)I FOR INSPECTIONS tXPIRES 1 YEAR FROM UATE ISSUE <br />JOB ADDRESS IA77 u LjC/ rizA ]])� CITY/ZIP J� f1 J <br />CROSS STREET At+ APN///� (/bO - -x PARCEL SIZE r <br />OWNER NAME .1 / /1f'X6iJC-r� O � ��V1.1 kI fir <br />1 � PHONE <br />� <br />y�l <br />OWNER ADDRESS ✓/'r'f&- CITY/STATE/ZIP <br />` �-y r <br />CONTRACTOR M 1111"—S(=IC <br />111 �6A!4�]`G► -r _ PHONE iq �(ly, C, <br />CONTRACTOR ADDRESS CITY/STATE/ZIP yC_✓l i `� /�.���+ <br />LICENSE I I C-42 I I C-36 OTHER NUMBER EXPIRATION DATEC�✓X <br />l /I11 I <br />WATER TABLE DEPTH: O ! VO 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 DESTRUCTIONIb <br />INSTALLATION WILL SERVE: tooll-ESIDENCE ❑ COMMERCIG ❑ OTHER <br />NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: NUMBER OF EMPLOYE <br />SEPTIC TANK TYPE/MFG �o t/ CAPACITY gal # OF CO TM jN jS <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal #0 9RTMENTS - <br />DISTANCE TO NEAREST: WELL ft FOUNDATION ft PRc�L�UAQu/N COU ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARMITR'( TEM) <br />..... __..... _.._.._. _.. / <br />M / LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES / ft <br />DISTANCE TO NEAREST WELL 1`'} ft FOUNDATION 5.57/ ft PROPERTY LINE 75� ft <br />❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft <br />DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br />SEEPAGE PITS NUMBER % WIDTH 3(or' ft DEPTH--+I,ft <br />DISTANCE TO NEAREST WELL _ ft FOUNDATION lti' ft PROPERTY LINE �ZLI 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 COMPENSAIION LAWS. <br />MINIMUM H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953- 697 <br />Gr <br />SIGNED TITLE 0A e�c/`r DATE <br />Application Accepted <br />Final Inspection By_ <br />Character of Soil to D <br />COMMENTSTE <br />Date <br />Area -'I <br />❑ SPE <br />Pit/Sump Soil Character: <br />Employee ID#� <br />PERMIT - Approved by <br />PE <br />SC <br />Received <br />Ch <br />Amount <br />Permit/ <br />Codec <br />INFO <br />B <br />Cas <br />emits d <br />Date Service # <br />Invoice # <br />Permit ID# <br />v <br />Se <br />pRequest <br />!%�� <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />