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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SA`N JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUN L IT CALL JOB ADDRESS CROSS STREET ftw M? OWNER NAM 'y OWNER ADDRESS 2— CONTRACTOR CONTRACTOR PAVy FOR INSPECTION$ - tXPIRES 1 YEAR FROM] U_4TE ISSUEI _I Iw/w�Nw1 CITY/ZIP L-4 ,/ 1ywj -11( J LS 1k„/ p _ APN t ju L r �l ! _ 401 PARCEL SIZE M CONTRACTOR ADDRESS —I W V ■ " LICENSE )t', C-42 [1 IC -36 OTHER NUMBER PHONE �+ CITY/STATE/ZIP L IJ� �' ` 2— L Iy L PHONE 64 CITY/STATE/ZIP (� �y EXPIRATION DATE WATER TABLE DEPTH: 7" ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION PP�� 1K REPAIR/ADDITION I ENGINEER DESIGNED /ALTERNATIVE X REPLACEMENT 4- n K OUT -OF -SERVICE SEPTIC SYSTEM -1 DESTRUCTION INSTALLATION WILL SERVE: G( RESIDENCE ❑ COMMERCIAL +.� ❑ OTHER NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: 1 NUMBER OF EMPLOYEES: SIGNED V Sc INFO ReceivedChe B sh Amount Remitted SEPTIC TANK TYPE/MFG U -CAPACITY gal # OF COMPARTMENTS Invoice # ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft LIFT STATION SIZE TYPE OF PUMP I,A ❑ PKG TX PLANT L3 SAND OIL SEPARATOR (ENCLOSED SYSTEM) p W ft Ain LENGTH OF LINES 1 x__1 LEACH LINES LEACHING CHAMBERS'T # OF LINES DISTANCE TO NEAREST WEL'' it FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH PA l/ mit ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIRES ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH CI VEn ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LM ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH Q R ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY) AQUI AIPj ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ENTAL ft DEPTH HEALTH pE_ ft j Ift1VT DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft •A/ SEEPAGE PITS NUMBER L WIDT ft DEPTH ft DISTANCE TO NEAREST WELL 750 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 DATE DEPARTMENT USE ONLY C 1' IUn Application Accepted By Date I I ' 1 �. . Area L1 I Employee ID# W Final Inspection By YM Date ID7 ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: PiVS/umP Soil Character: COMMENTS _ I b e /aim A ;4i0 Add; r` N 144 Soo 4ic)W1 WO CCI 11(d 4, 8 � A ICO( f ig . S (A A,40 %el rc'e 9 P d- f e C 0 U), A h 1(o(X� l.r, fill, m I . . .1" r_I L, v I O _ ,.I1 _ . 1 1,//, IF J PE Code V Sc INFO ReceivedChe B sh Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 23 r p W T d r i it CC GSsfJ' DATE DEPARTMENT USE ONLY C 1' IUn Application Accepted By Date I I ' 1 �. . Area L1 I Employee ID# W Final Inspection By YM Date ID7 ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: PiVS/umP Soil Character: COMMENTS _ I b e /aim A ;4i0 Add; r` N 144 Soo 4ic)W1 WO CCI 11(d 4, 8 � A ICO( f ig . S (A A,40 %el rc'e 9 P d- f e C 0 U), A h 1(o(X� l.r, fill, m I . . .1" r_I L, v I O _ ,.I1 _ . 1 1,//, IF J PE Code V Sc INFO ReceivedChe B sh Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 23 42-01 5/5/17 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT T