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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT Ite- SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NAN-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED OFxADDRESS (2-4 01 N I S STREET �/-�MAn `n -t NER NAME V� I OWNER ADDRESS 24 50 l -7 CITY21P A �a mn0 gc0120 A[��.U// -M- %%I� PARCEL SIZE Q a (� VlC`- ' l..-9 ✓`�--•PHONE20 I- bO-1- 0 -L____`7 _ CONTRACTOR �� __. CONTRACTOR ADDRESS LICENSE ❑ C-42 ❑11C-36 OTHER CITY/STATE/ZIP go CIA G� PHONE CITY/STATE/ZIP NUMBER EXPIRATION DATE___ _ WATER TABLE DEPTH: �r/ 4 `� ft GEOGRAPHICAL INFORMATION: COordl aces X Y PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION RE AIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE I REPLACEMENT I I OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE:RESIDENCE ElCOMMERCIAL OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS://.. 00,,ll NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG �& oocrek �- CAPACITY � gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL 3 ft FOUNDATION ft PROPERTY LINE /00 ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) NIMUM 2 OUR A VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED _ TITLE _ DATE ill -�X) h EPARTMF_NT SE ONLY Application Accepted By ate ea. ll Employee ID# Final Inspection By 36P CIAL PERMIT - Approved by Character of Soil to ;fie of F U P*VSump Soo haracter: COMMENTS ��L PE Code 876-5-)- , Received By LEACH LINES ❑ LEACHING CHAMBERS # OF LINES LENGTH OF LINES ft 90 a� ft DISTANCE TO NEAREST WELL ft FOUNDATION_ft PROPERTY LINE ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft 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 It PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft XSEEPAGE PITS NUMBER WIDTH ft DEPTH OSS ft DISTANCE TO NEAREST WELL h50 ft FOUNDATION O ft PROPERTY LINE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAI 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 COMPENSATIQN LAWS. NIMUM 2 OUR A VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED _ TITLE _ DATE ill -�X) h EPARTMF_NT SE ONLY Application Accepted By ate ea. ll Employee ID# Final Inspection By 36P CIAL PERMIT - Approved by Character of Soil to ;fie of F U P*VSump Soo haracter: COMMENTS ��L PE Code Sc INFO Received By ash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 6 2- �o 42-01 ONSITE WASTEWAT RTMNT SYSTEM PERMIT 5/5/17 //- //7