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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SCAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT GALL 21)19 953 JOB ADDRESS CROSS STREET eff /� OWNER NAME — r //Ca�L��_ OWNER ADDRESS 2cA 2 9j Gl CONTRACTOR CONTRACTOR ADDRESS LICENSE L11_IC-42 ❑ 'C-36 OTHER -,(69/ FO#H INSPECTIONS tXPIHLS I T LAH t -HUM. vA I t rabUtl. CITY/ZIP APN t{_ 77/ / _[ !?P2 -1]e PARCEL SIZE f 1461-- PHONEZ p "1 2- CITY/STATE/ZIP CITY/STATE/ZIP PHONE CITY/STATE/ZIP NUMBER EXPIRATION WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X P� ❑ PERC TEST # D LEACHING CHAMBERS Check#/ BUILDING PERMIT # # OF LINES LAND USE APPLICATION #7 LENGTH OF LINES TYPE OF WORK: _ NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIG ED/ALTERNATIV WELL D REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL 0 OTHER FILTER BED WIDTH NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG _ _ CAPACITY gal # OF COMPARTMENTS FOUNDATION DISTANCE TO NEAREST: WELL It FOUNDATION - _ ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES D LEACHING CHAMBERS Check#/ Amount # OF LINES Permit/ Invoice # LENGTH OF LINES ft INFO B DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION 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 ft 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 CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. SIGNED Application Accepted By Final Inspection By Character of Soil to De COMMENTS -— ED FOR INSPECTIONS - PLEASE CALL (209) 953-7 TITLE , DATE T DEPARTMENT USE;ONL,,Y Date I Area _A Employee ID# T Date_�� ❑ SPECIAL PERMIT - Approved by Pit/Sump Soil Character: T PE SC Received Check#/ Amount Date Permit/ Invoice # Permit ID Code INFO B Cash Remitted Service Request # "' I q I SR oO� 83 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 cY�