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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAOUI� COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NGV -REFUNDABLE PERMIT GALL 209) 953-7697 FOR INSPECTIONS )F tXPIRES 1 YEAR FROM UATE ISSUEI JOB ADDRESS / �� S' J1 1,011 CITY/ZIP) ZI�'j� a k/'6A r CROSS STREET � APN l ©D T PARCEL SIZE r` 7 OWNER NAME J/i f// �/r %'!1 n Ad JAI _-__ _ PHONE��9 OWNER ADDRESS � d / �f/ /' 4 /.10/.-P' _- CITY/STATE/ZIP0J e-41-0.4 CONTRACTOR ��S /� /GAS �C� r PHONE CONTRACTOR ADDRESS �O CITY/STATE/ZIP LICENSE t --C-42 ❑TIC -36 OTHER NUMBERr.�76"a EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: PERC TEST # BUILDING PERMIT # Coordinates X Y LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE CI COMMERCIAL [I OTHER NUMBER OF LIVING UNITS: ` NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK ❑ GREASE TRAP ❑ LIFT STATION TYPE/MFG TYPE/MFG DISTANCE TO NEAREST: WELL SIZE TYPE OF PUMP CAPACITY CAPACITY ft FOUNDATION Ll PKG TX PLANT gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) 1 EACH 1 INFC 7 1 FACHING CHAMRFRS it nF I INF. I FNGTH nF t_INES /vv , 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 Bye Character of Soil to Dept COMMENTS -rw ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (20 TITLE #,A I S 4'L r DATE DEPARTMENTT USE ONLY ,1 �- Date Area Emp►j7 ee !D# fi-�c I Date EISPECIAL PERMIT. Ap OVAENT __ Pit/Sump Soil Character: E(;EIVc S d S SAN JOAQUIN Col w s o t S _ �` ��N PE DISTANCE TO NEAREST WELL hec ft FOUNDATION Permit/ ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH Remitted ft DEPTH ft DISTANCE TO NEAREST WELL r�4 ft 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 ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ___ It LENGTH ft DEPTH ft DISTANCE TO NEAREST 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. SIGNED Application Accepted By Final Inspection Bye Character of Soil to Dept COMMENTS -rw ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (20 TITLE #,A I S 4'L r DATE DEPARTMENTT USE ONLY ,1 �- Date Area Emp►j7 ee !D# fi-�c I Date EISPECIAL PERMIT. Ap OVAENT __ Pit/Sump Soil Character: E(;EIVc S d S SAN JOAQUIN Col w s o t S _ �` ��N PE SC Received hec Amount Date Permit/ InvoicVVLTH DEPAR6Tj#f -p# Code INFO By Cash Remitted Service guest # 45— CIO 1110 816- r�4 MTN I 42-01 ONSITE WASTFWATER TRTMNT SYSTEM PERMIT 5/5/17