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• ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 I:iON-REFUNDABLE PERMIT CAPACITY gal # OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS ft FOUNDATION It PROPERTY LINE ft ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) GALL 209 953-7697 FOR INSPECTIONS tXPIRES 1 YEAR FROM LIATE ISSUED JOB ADDRESS ( S� + _CITYIZIP �+qnGiC Y[ /1 L 17 g�� 1 C!�p�d' Q r ©p U S U o.,) CROSS STREET M rLfi APN G PARCEL SIZE -3z4 ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft Q I y �r OWNER NAME 1 U 7 C. V /)Ut PHONE OWNER ADDRESS S C, Q ---CITY/STATE/ZIP ft FOUNDATION in, It PROPERTY LINE ft CONTRACTOR Y, 1�L IGS AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN - i� PHONE ?1 ^ v! CONTRACTOR ADDRESS -19 - Ck /�-L 4>S� __CITY/STATE/ZIP j�c/{ /� f�c� .19C,4 i SIGNED TITLE��1 PY q C A41^DATE 1,,)L -.15 e 7 1�3 LICENSE ❑ IC -42 EIC -36 OTHER NUMBER '4PIRATION DATE � WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: ❑ PERC TEST # BUILDING PERMIT # -- TYPE TYPE OF WORK: NEW INSTALLATION EPAIR/ADE Coordinates X Y LAND USE APPLICATION # )N _1 ENGINEER DESII REPLACEMENT I I OUT -OF -SERVICE SEPTIC SYSTEM 1 1 DESTRUCTION _ INSTALLATION WILL SERVE: 'Q/R€SIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: TERNATIV E ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE _. TYPE OF PUMP CAPACITY gal # OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS ft FOUNDATION It PROPERTY LINE ft ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LI LEACHING CHAMBERS 1 # OF LINES �_ LENGTH OF LINES ft Amount Remitted ( S� DISTANCE TO NEAREST WELL It FOUNDATION /0 ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LEN TH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ MOUNDED WIDTH LENGTH _ ft DEPTH PA)*P-Ai It --ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE REcEN-fes It ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft – DISTANCE TO NEAREST WELL _ ft FOUNDATION ft PROPERTY LINE ft El DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH Eru q.' UPMC-fIj' ft DISTANCE TO NEAREST WELL SEEPAGE PITS NUMBER_ WIDTH 1� ft FOUNDATION ft PROPERTYILINE��DENR4M�� It �� ft DEPTH _� ft DISTANCE TO NEAREST WELL ft FOUNDATION in, It 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 CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOU DVANCE NOTICE REQUIRED FOR INSPECTIONS -P—LEASE CALL 209 953-7697 SIGNED TITLE��1 PY q C A41^DATE 1,,)L -.15 e 7 Application Accepted Final Inspection By Character of Soil to D COMMENTS / UtF'HHIMtNI V5 FI– Date �,Area �f Employee ID# Dat ❑ SPECIAL PERMIT - proved b of 3 Ft: PRIS OCharacter: PE Code SC INFO Received B Chec as Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# i N S �- �3 ! S 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17