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ONSITE WASTEWATER TREE-iMENT SYSTEM PERMIT �v SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES; 1 YEAR FROM DATE ISSUED JOB ADDRESS /4.4 / )&1 t ' �� T%�� "I -,(l -CITY/ZIP Z. i 7 O CROSS STREET �' � APN � UQ � ' j PARCEL SIZE �J' OWNER NAME�D,>fio j +/V�—/ / PHONE OWNER ADDRESS CITY/STATE/ZIP t!-'ONTRACTOR PHONE r� CONTRACTOR ADDRESS U ` CITY/STATE/ZIP �I--1z� LICENSE P� C-42 FJ C-36 OTHER A NUMBER EXPIRATION DATE WATER TABLE DEPTH: ❑ PERC TEST #_ TYPE OF WORK: L`/v —ft GEOGRAPHICAL INFORMATION: BUILDING PERMIT # NEW INSTALLATION REPAIR/ADC Coordinates X Y_ LAND USE APPLICATION # IN ENGINEER DESIGNED REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM I DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: iL NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE TYPE OF PUMP CAPACITY CAPACITY It FOUNDATION _ ❑ PKG TX PLANT TERNATIVE gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) -PLEASE 4LCI►14-91 DATE DEPARTMENT U ONLY Application Accepted By Date _ Are Employee ID# Final Inspection By Date lz/*/Ah�/_7 ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft:'_ _ PIVSumP Soil Character: G_ �� 6u COMMENTS Tt - = , 1 AV,) F(L+gA: T_0w.J , PE Code LEACH LINES ❑ LEACHING CHAMBERS # OF LINES LENGTH OF LINES (J, , ft Check#/ DISTANCE TO NEAREST WELL 014 it �� , FOUNDATION 2UZ4 ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft l7 DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It 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 _ ft LENGTH _ ft DEPTH ft DISTANCE To NEAREST WELL ft FONDATION ft PROPERTY LINE ft SEEPAGE PITS NUMBER WIDTH .1 / ft DEPTH fLS_ ft DISTANCE TO NEAREST WELL Q _ It 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. -PLEASE 4LCI►14-91 DATE DEPARTMENT U ONLY Application Accepted By Date _ Are Employee ID# Final Inspection By Date lz/*/Ah�/_7 ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft:'_ _ PIVSumP Soil Character: G_ �� 6u COMMENTS Tt - = , 1 AV,) F(L+gA: T_0w.J , PE Code SC INFO Received By Check#/ Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# l7 QCash O 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 T