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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT f/ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT GALL (2U9) 953-7697 FOR INSPECTIONS tXPIRES 1 YEAR FROM UATE ISSUEI JOB ADDRESS.1 ,�l �� I//C��CJ CITY/Zip Ci S �-. .� i� CROSS STREET .S�i z L. (�.`' i t4�.J APN V " D _ PARCEL SIZE O ' # OF LINES LENGTH OF LINES ft GG r C, r u oldP V WELLC1 OWNER NAME FOUNDATION D ft PROPERTY LINE Ij)' ft ❑ FILTER BED PHONE _ OWNER ADDRESS SC1 rAC / _ CITY/STATE/ZIP . CONTRACTOR _ _ill I �f,,.� �� -,C K& &T- ' PHONE q sic ' Ci CONTRACTOR ADDRESS �v CITY/STATE/ZIPy1'l�'•i 1L ---9L LICENSE LI C-42 ❑' C-36 rF�''��'1� OTHER NUMBER -EXPIRATION DATE DISTANCE TO NEAREST WATER TABLE DEPTH: 'OL/75 ft GEOGRAPHICAL INFORMATION: LI PERC TEST # BUILDING PERMIT #� TYPE OF WORK: NEW INSTALLATION REPAIR/ADC Coordinates X _ Y LAND USE APPLICATION # )N ENGINEER DESIGNED 11 REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ESIDENCE I I COMMERCIAL i OTHER__ NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:__ NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE TYPE OF PUMP CAPACITY CAPACITY ft FOUNDATION ❑ PKG TX PLANT TERNATIVE gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE It ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) 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. UIRED FOR INSPECTIONS - SIGNED TITLE �""� �) YL`C uN DATE DEPARTMENT USE ONLY Application Accepted By Date G ' Area – � I Employee ID# A h m e Final Inspection By Date ?O ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character:�'�_ COMMENTS T.;, 2. CGS i IdrAi�!/r► — --- PE Code SC INFO Received B Check ash i �� {d LEACH LINES 11 LEACHING CHAMBERS Invoice # # OF LINES LENGTH OF LINES ft U DISTANCE TO NEAREST WELLC1 ft FOUNDATION D ft PROPERTY LINE Ij)' ft ❑ FILTER BED WIDTH _ _ . _._ _ _ ft LENGTH _ ft DLPTH PAva, ft DISTANCE TO NEAREST WELL ft w r FOUNDATION _ ft PROPERTY LI� ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH Enft DISTANCE TO NEAREST _ WELL ft FOUNDATION ft PROPERTY I@ ft �- •• ❑ SUMPS WIDTH ft LENGTH VV ft ft DEPTH DISTANCE TO NEAREST WELL ft 1. FOUNDATION ft PROPEL `�� IAQUI�I_Coi l,ft ❑ DISPOSAL PONDS WIDTH _ _ ft LENGTH ft DEPTH �LTHff��E� __N�-rAt?? ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINEMENT ft u SEEPAGE PITS NUMBER WIDTH i_ I� ft DEPTH ,� 5 I ft DISTANCE TO NEAREST WELL I.S`g i ft FOUNDATION�1 ft PROPERTY LINE I,.3I 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. UIRED FOR INSPECTIONS - SIGNED TITLE �""� �) YL`C uN DATE DEPARTMENT USE ONLY Application Accepted By Date G ' Area – � I Employee ID# A h m e Final Inspection By Date ?O ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character:�'�_ COMMENTS T.;, 2. CGS i IdrAi�!/r► — --- PE Code SC INFO Received B Check ash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# U CJS 2is'3 — 42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 T