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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESSI %]_� CIT�Y�/ZI%P�[�� L(%l /f" —/ �"]' 7��LI7 CROSS STREET � � APN b3 -1 _ . PARCEL SIZE OWNERNAME PjH(7O1N41_ - � C[J OWNER ADDRESS CONTRACTOR PHONE' �G r-71 CONTRACTOR ADDRESS �S 'r - _ CITY/STATE/ZIP LICENSE A C-42 ❑ 'C-36 OTHER NUMBER ,:%S� SEXPIRATION DATE_ ,v / WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X _ Y # OF COMPARTMENTS PERC TEST # TYPE/MFG _ BUILDING PERMIT # _._. _ LAND USE APPLICATION # Permit ID# TYPE OF WORK: NEW INSTALLATION nEPAIH/ADDITION ENGINEER DESIGNED /ALTERNATIVE ❑ LIFT STATION REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION WELL ft FOUNDATION _ ft PROPERTY LINE ft INSTALLATION WILL SERVE: RESIDENCE I COMMERCIAL 11 OTHER_ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: Z__ NUMBER OF EMPLOYEES: DISPOSAL PONDS WIDTH SEPTIC TANK TYPE/MFG � _ 1— CAPACITY [ Zw_ _._ gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG _ CAPACITY gal # OF COMPARTMENTS Permit ID# L DISTANCE TO NEAREST: WELL 5D +" _ it FOUNDATION I o + _ ft G PROPERTY LINE rl It ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) SIGNED Application Accepted By k Final Inspection By Character of Soil to Depth of Ft: _ COMMENTS &_&i /0 4-n G 121 DATE 10NrI�a10af51 DEPARTMENT USE ONLY � ^ Date_ _ _ Area _`� ,{{_ Employee ID# Date_ __ I I SPECIAL. PERMIT - Approv dpy __ PIUSump Soil Character: ___ j P✓` N wr PE Code LEACH LINES LEACHING CHAMBERS �!1___`�____l_lN�or LINES _�,,t „LENGTH OF LINES ft ReceivedCheck B DISTANCE TO NEAREST } WELL -` ft FOUNDATION 1 ) ft PROPERTY LINE S ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft Permit ID# DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft / DISTANCE TO NEAREST WELL ft FOUNDATION _ ft PROPERTY LINE ft SUMPS %G� WIDTH / _ ft LENGTH — _ 110_ ft DEPTH � ft DISTANCE TO NEA EST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. SIGNED Application Accepted By k Final Inspection By Character of Soil to Depth of Ft: _ COMMENTS &_&i /0 4-n G 121 DATE 10NrI�a10af51 DEPARTMENT USE ONLY � ^ Date_ _ _ Area _`� ,{{_ Employee ID# Date_ __ I I SPECIAL. PERMIT - Approv dpy __ PIUSump Soil Character: ___ j P✓` N wr PE Code SC INFO ReceivedCheck B ash Amount Remitted to Permit/D Service Request # Ir.vcice # Permit ID# a / 42-01 5/5/17 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT rn