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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON C A 95205•(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 9-5/3-7697 FOR INSPECTIONS EXPIRES 1 EAR FROM DATE ISSUED <br /> Joe ADDRESS _ rtl 017,- Ln <br /> { <br /> CROSS STREET APN Of <br /> 5s 1 0 1 PARCEL SIZE •I s <br /> e <br /> 0 <br /> OWNER NAME .�.� l£,?f� ___PHONE <br /> �J A .....__..._.....__....._..__.______ <br /> OWNER ADDRESS v1/ `w/( O�+T� CmR.TATEMP <br /> CONTRACTOR `— /'7C/lG_[i,i��J�.6IC. ___--_-- PNONE /�— <br /> CC+NTRACTOR ADDRESS 10161.4 4-1304 <br /> A •� / _._—_ CITV/STATE/ZIP �{y� z � <br /> LICENSE 'i 'C-42 ❑ C-36 OTHER -130��� NUMBER�� EXPIRATION DATE ?V�v <br /> WATER TABLE DEPTH: - i it GEOGRAPHICAL INFORMATION: Coordinates X_ Y <br /> PERC TEST N BUILDING PERMIT#___ LAND USE APPLICATION# <br /> TYPE OF WORK: NEW INSTALLATION REPAM/ADDITION ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION SF•/'�/.0//��✓!� <br /> INSTALLATION WILL SERVE: RESIDENCE I I COMMERCIAL OTHER <br /> J NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> J� SEPTIC TANK TYPE/MFG CAPACITY ._ gal #OF COMPARTMENTS _.._ <br /> ❑ GREASETRAP TYPE/MFG _....—___ CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ___ R FOUNDATION ____ it PROPERTY LINE it <br /> ❑ LIFT STATION SIZE TYPE OF PUMP __U PKG TX PLANT O SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS _----_----._._,___ #OFUNES _ LENGTHOFLINES it <br /> DISTANCE TD NEAREST WELL it FOUNDATION _It PROPERTY LINE It <br /> ❑ FILTER BED WIDTH _It LENGTH it DEPTH It <br /> DISTANCE TO NEAREST WELLN FOUNDATION __ft PROPERTY LINE It <br /> ❑ MOUNDED WIDTH _ R LENGTH it DEPTH it <br /> DISTANCE TO NEAREST WELL _ If FOUNDATION ft PROPERTY LINE fl <br /> ❑ SUMPS WIDTH __it LENGTH K DEPTH ft <br /> DISTANCE TO NEAREST WELL __ R FOUNDATION ft PROPERTY LINE It <br /> ❑ DISPOSAL PONDS WIDTH It LENGTH H DEPTH It <br /> DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE It <br /> ❑ SEEPAGE PITS NUMBER _ _.__ WIDTH__._____ It DEPTH it <br /> DISTANCE TO NEAREST WELL_ __ it FOUNDATION It PROPERTY LINE it <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATI N LAWS. <br /> M/N1MU OU C_F_ OTICE!REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-76/97 <br /> SIGNED C _y _ TITLE..__ ._._ ��_ DATE <br /> IL <br /> I <br /> R <br /> cr' tias kA R u <br /> r <br /> EP TATE ) <br /> Application Accepted By Date.._� — Area G Employee ID# WUn y <br /> Final Inspection By Date _[Q ❑ SPECIAL PERMIT•Approved by <br /> Character of Soil to Depth o}�Fh Pit/Sump Soli Character: <br /> COMMENTS CGMtAVr/(�;cl14 '1 be 1^c LI She l/ Well iS <br /> rinc < <br /> PE SC Race ved Choc Amount Date Permit/ Invoice N Permit IDN <br /> Code INFO BY sh Remitted Service R uest# <br /> ya.a 0 IZ Z <br /> 42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 6!5117 <br />