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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT Q SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT GALL ZO 953-7697 FOR INSPECTIONS LXPIRES l YEAR FROM DATE I55UE1 JOB ADDRESS TYPE/MFG CAPACITY gal CITYIZIP 40 J DISTANCE TO NEAREST: WELL G Sy ft FOUNDATION ] ' 10 ft PROPERTY LINE � ft E3 LIFT STATION 0 O 0 L3PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ft CROSS STREET r t� DEPTH I Z It A P N D t*j " DISTANCE TO NEAREST PARCEL SIZE OWNER NAME m� AI e�r-� t � `' n F ONE cL WIDTH ft LENGTH ft DEPTH ft OWNER ADDRESS DISTANCE TO NEAREST WELL L7c7S�IT /STATE/ZIP FOUNDATION ft PROPERTY LINE CONTRACT �Ii��/� y.r e-nS� 77 bWhCY_ �Lif�pIPHONE 01) LENGTH _ CONTRACTOR ADDRESS DEPTH .S GMS CITY/STATE/ZIP DISTANCE TO NEAREST WELL LICENSE ❑ C-42 ❑ C-36 OTHER NUMBER_ EXPIRATION DATE ❑ DISPOSAL PONDS WIDTH ft WATER TABLE DEPTH: I ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT # Y- LAND USE APPLICATION # TYPE OF WORK: *I"- NEW INSTALLATION i REPAIR/ADDITION [ ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT I I OUT -OF -SERVICE SEPTIC SYSTEM I I DESTRUCTION INSTALLATION WILL SERVE: ' RESIDENCE I:1 COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: I- NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG �� / cD S CAPACITY �a V U gal # OF COMPARTMENTS–?- OMPARTMENTS❑ 0GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS WELL DISTANCE TO NEAREST: WELL G Sy ft FOUNDATION ] ' 10 ft PROPERTY LINE � ft E3 LIFT STATION SIZE TYPE OF PUMP L3PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES ❑ LEACHING CHAMBERS Received # OF LINES LENGTH OF LINES ft Permit/ DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft FILTER BED WIDTH '32 gr ft LENGTH"' ft r t� DEPTH I Z It ► DISTANCE TO NEAREST _ WELL It FOUNDATION / ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft 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 ft LENGTH ft DEPTH ft DISTANCE TO NEARL'�T WELL ft 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. MINIMUM 24 HOUR ADV CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 20 SIGNED 777�_ TITLE DATE DEPARTMENTISE NLY �M Application Accepted 5 , Date �� _�� area Employee iD# v �t Final Inspection By Date ❑ SPECIAL ERMIT - Approved by Character of Soil to epth of 3 Ft: Pit/Sump Soil har ter: T /�� COMMENTS OA t c 7f J �, ,4-,�.,1. n {6 71w AAAA -113 41:2 Awl—SP-ZI V PE SC Received heck#/ -C—asFF Amount Da Permit/ Invoice # Permit ID# Code INFO B -V Remitted Service Request # 2t ► X3`77 l 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17