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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL(20p) 953-7697 FOR INSPECTIONS EXPIRES] 1 YEAR FROM DATE ISSUED JOB ADDRESS f CITY /ZIP S kill) !/ CROSS STREET S Q APOSq-/00 PARCEL SIZE OWNER NAME ~� ` M PHONE OWNER ADDRESS — _ —CITY/STATE/ZIP i ` CONTRACTOR I ` Sty PHONE J 7 s-3 ,r CONTRACTOR ADDRESS ii / l,"Z'L-J / /�` CITY/STATE/ZIP �f�/� • �? J •T S `r LICENSE ❑ IC -42 ❑JC -36 OTHER NUMBER / `' 'EXPIRATION DATE WATER TABLE DEPTH: - U UU ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION i ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG I 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 # OF LINES LENGTH OF LINES ft ^ r DISTANCE TO NEAREST WELL It ft FOUNDATION ft PROPERTY LINE �y 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 ft Nk SUMPS WIDTH ft LENGTH / �L ft DEPTH ft DISTANCE TO NEAREST WELLVO _ ft FOUNDATION ft PROPERTY LINE c t El DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH Ktcelypr It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH J"jt" " ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LIN ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCte fRl4® JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICE T CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. r MINIMUM HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 /953-7697 �1 SIGNED / TITLE DATE '2 O Application Accepted By Final Inspection By Character of Soil to Depth of 3 Ft: COMMENTS TSS tNAHIMtN/ AJ S It UJV LY Date Area , Employee ID#�" gate /p 7 _ _ El SPECIAL PERMI- Apprcred by f Ol fes- Pit/Sump Soil Character: / PE Code SC INFO Received B h ash Amount Re 'tted Date Permit/ Service Request # Invoice # Permit ID# A-UO7 42-01 5/5/17 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT T