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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 />IVUN-hhI-UF,1JAI3LE PERMIT L:ALLZUy `953-/b41 FOR INSPECTIONS tXPIRES 1 YEAR FROM DATE ISSUEI <br />JOB ADDRESS CITY/ZIP Jf)'Oen <br />CROSS STREET /� e4!clx APN _� 020, PARCEL SIZE O <br />OWNER NAME __5'Li <br />CI"C'/rI Y <br />PHONE <br />Cash <br />j►1 <br />OWNER ADDRESS / <br />J�`ZV <br />( -/ �'-_/r�2 <br />r' <br />[J _ CITY/STATE/ZIP <br />Invoice # <br />CONTRACTOR <br />/ `S /► i� SLS <br />�✓ C'� PHONE <br />PHONE <br />ft <br />CONTRACTOR ADDRESS <br />_ �D "9 <br />CITY/STATE/ZIP a /i <br />a "P'. /z: <br />LICENSE/C-42 <br />C-36 OTHER <br />NUMBER / ` EXPIRATION DATE <br />7 � — 7- z7Z <br />WATER TABLE DEPTH: � ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />J PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATI N REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT L OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: L RESID NCE 1 COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: / NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: �f <br />SEPTIC TANK TYPE/MFG CAPACITY �Z �l �l gal # OF COMPARTMENTS ` <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />f <br />DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />I LEACHING CHAMBERS <br />Received <br />B <br />Cash <br /># OF LINES <br />Date <br />LENGTH OF LINES ft <br />Invoice # <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY LINE ft <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 />❑ 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 />❑ SUMPS <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 />❑ DISPOSAL PONDS WIDTH <br />ft <br />LENGTH <br />ft <br />DEPTH P n *...].f ft <br />DISTANCE TO NEAREST <br />WELL <br />ft <br />FOUNDATION <br />ft PROPERTY 'CUIL ft <br />❑ SEEPAGE PITS <br />NUMBER <br />WIDTH <br />ft DEPTH E L' ft <br />DISTANCE Tn NFARFST <br />WFI I <br />ft <br />Fnl INnATInN <br />MfE <br />ft PR.PFRTY I IN TH D;:,,, , N7AL 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 />SIGNED <br />Application Accepted By <br />A P0 <br />Final Inspection By wz <br />Character of Soil to Depth of 3 Ft: <br />COMMENTS L <br />- <br />el <br />TITLE_ - <br />X " <br />DATE f 7 -/ <br />TMENT U E (7NLnY <br />Date Area Employee ID# <br />Date , ❑ SPE IAL PERMIT -Approved by <br />Y <br />PE <br />Code <br />SC <br />INFO <br />Received <br />B <br />Cash <br />Amount <br />emitted <br />Date <br />Permit! <br />Service Request # <br />Invoice # <br />Permit ID# <br />� <br />I <br />l 2> -9q <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />rA <br />