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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 (� �C7ALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS o`Z-1 1 w 1C-(�c�n ILO P�!Q CITY21P M P�fVI CA 9533 - <br /> y <br /> ` "�` <br /> CROSS STREET V e1\U I.\ \�1 LII. APN//� U D / // PARCEL SIZE <br /> d <br /> OWNER NAME K/U('t�\Qrc )A P_r-ro-nckR'Ln _ y�� PHONE��O9) 595-908;2 7 v� <br /> r OWNER ADDRESS l�JCOC 1-1 W 111(>_1n Q'DAn CITY/STATE/ZIP I/ 1 9441CA qy ; T <br /> CONTRACTOR C �� PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE IJI IC-42 C-36 OTHER NUMBER EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> 1-1 PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# PA O <br /> TYPE OF WORK: I NEW INSTALLATION REPAIR/ADDITION ENGINEER D IGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION <br /> INSTALLATION WILL SERVE: RESIDENCE LI COMMERCIAL I OTHER <br /> NUMBER OF LIVING UNITS: L� NUMBER OF BEDROOMS: 17 NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG J 6` CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <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 /> CLi LEACH LINES LEACHING CHAMBERS #OF LINES LENGTH OF LINES 0 ft <br /> DISTANCE TO NEAREST WELL 100 t- ftFOUNDATION OI 1- ft PROPERTY LINE If <br /> 1 ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE It <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE 13A ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH Am <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH 13 ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 0' <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH 11 .. ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINEAE/JTI <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN EN <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 /> MINIMU 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 9^53-7697 <br /> SIGNED TITLE C9 i nR_l DATE A-� <br /> EPA RTMENT S ONLY <br /> Application Accepted By Date Area Employee ID#� <br /> Final Inspection By _ Date. I SPECIAL PERMIT-Approved by <br /> Character of Soil to Dept*3F Pit/Sump Soil Character: <br /> COMMENTS / 4Er C - 70 ( NLbIl <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO as h Remitted S rvice Request/# <br /> lf' <br /> nIX'_ 'Mon 1-7 16 <br /> 4 <br /> 7 <br /> fA"F - - - I - -I <br /> 4 5/2-01 <br /> 5/17/5/17 Sa7-7 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />