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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P ✓ SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL1 H DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT JOB ADDRESS CROSS STREET OWNER NAME OWNER ADDRESSX� .CONTRACTOR CONTRACTOR ADDRESS LICENSE ❑ C-42 11 C-36 OTHER GALL (2U9 9b3 -7b91 FOR INSPECTIONS LXPIRES l YEAR F M DATE ISSUE[ P Z U D Q / PARCEL SIZE -MY/STATE/ZIP �\ PHONE - -I_ I i1- - __CITY/STATE/ZIP __ NUMBER _ _ _EXPIRATION DATE_ WATER TABLE DEPTH: ft GEOGRAPHICAL_ INFORMATION: Coordinates X Y LPERC TEST # BUILDING PERMIT # _ _ I q 03 H .�2- LAND USE APPLICATION # TY E OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE 1 COMMERCIAL I OTHER NUMBER OF LIVING UNITS: 16 NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFGe_ID CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS D i ► �x # OF LINES _72- LENGTH OF LINES ft DISTANCE TO NEAREST WELL U'r ft FOUNDATION -2—S ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH __ .. ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE It ❑ SUMPS WIDTH ft LENGTH - ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTHft 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 By Character of Soil to D COMMENTS DEPARTMENT USE ONLY __ Date Area Employee ID# A Date— _el'��'_I « ❑ SPECIAL PERMIT - Approved by 61 L ra, Pit/Sump Soil Character: PE Code SC INFO Received B Check / s Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# oil,55� t3 S -i 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 r�