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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT I LP ✓ SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUND/ALA P„ IyIIT BALL (209) 953-7697 FOR INSPECTION^ F (PIRES 1 Y AR FF I�p.D�Tg ISAIU JOB ADDRESS CROSS STREET t P — GL U — U I PARCEL SIZE OWNER r1■'Gd0%wJmiim,��--7AREIF11:WuM"AlLpr ToAJw1� is �18 _CONTRACTOR D -A.- c' 6167 CONTRACTOR LICENSE iC-42 F1 C-36 OTHER NUMBER I M5 k 1. EXPIRATIONDATE` WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION I REPAIR/ADDITION ENGINEER DESIGNED /ALTERN TIVE ❑ REPLACEMENT 1 OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE U COMMERCIAL I 1 OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 'k 3 NUMBER OF EMPLOYEES: _ `0 SEPTIC TANK TYPE/MFG .Imo-- CAPACITY K:) U U gal # OF COMPARTMENTS L ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS ft DISTANCE TO NEAREST: WELL ft FOUNDATION ft ��'' PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS 247# OF LINES LENGTH OF LINES 40 ft DISTANCE TO NEAREST WELL 100+ ft FOUNDATION 50'f ft PROPERTY LINE zi} ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTII ft LENGTH ft DEPTH ft DISTANCE TO NEAREST of WELL It FOUNDATION SUMPS WIDTH 44�ft L NGTH IO/ 'eft ft PROPERTY LINE DEPTH ft ft DISTANCE TO NEARES WELL ft FOUNDATION �lJ* ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKEB&COMPENSATION LAWS. ED FOR Application Accepted Final Inspection By_ Character of Soil to D COMMENTS A Employee ID# AL PERMIT - Approved by t+f PE SC Received hec Amount Date Permit/ Invoice # Permit ID# Code INFO By Cash Remitted Service Request # 42-01 v�� (�yv �- / ( ONSITE ASTEWATER TRTMNT SYSTEM PERMIT 5/5/17