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ONSITE WASTEWATER TREATM[7-..NT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS XPIRES 1 YEAR FROM DATE ISSUEI ' ,py JOB ADDRESS % TO % �y, LENGTH OF LINES CITY/ZIP Invoice # CROSS STREET - UV �OWNER NAME fyC 'e/��%� OWNER ADDRESS /-` z ��%[// WELL APN D S� �/ �e2c PARCEL SIZE PHONE S ft Lo/! e:4 ';�52-y 2- Ste` /� v _ _ CITY/STATE/ZIP CONTRACTOR / Q L/- _ _ PHONE 7— o 32-7 - 2-7571 it - ov CONTRACTOR ADDRESS WELL CITY/STATE/ZIP FOUNDATION LICENSE ❑ C-42 1_1 C-36 OTHER NUMBER EXPIRATION DATE.--- _ _ WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION ii REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE X- REPLACEMENT F-! OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL I 1 OTHER NUMBER OF LIVING UNITS: ` NUMBER OF BEDROOMS: Z NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY ❑ GREASE TRAP TYPE/MFG CAPACITY DISTANCE TO NEAREST: WELL _ _ ft FOUNDATION ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES /LEACHING CHAMBERS Received # OF LINES 44 LENGTH OF LINES S It Invoice # DISTANCE TO NEAREST WELL It FOUNDATION 10 It PROPERTY LINE ft ❑ FILTER BED WIDTH It LENGTH ft DEPTH it - ov DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH _ ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft 1 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. 9 SIGNED Application Accepted BVI— Final Inspection By Character of Soii zo Depth of 3 Ft: COMMENTS 59.,.crL—Ic.r BRED FOR INSPECTIONS - TITLE _ OWVIe V" DATE I I } DEPARTMENT USE ONLY Date �� I_ Area f Employee ID# Date ❑ SPECI L PERMIT - Approved by Dit/Sump Soil Character: ff PE SC Received Check#/ Amount Date Permit/Code Invoice # Permit ID# INFO B ash Remitted Service Request # L l - ov 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 T