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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-HEFUNDABLE HERMIT GALL ZU9 V53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI JOB ADDRESS R _ ) CITY/ZIP ,, r �7iZz7 CROSS STREET V APN _ 1.0 � Li PARCEL SIZE 0 OWNER NAMET?i�Y_ �i T (9' _�i PHONE OWNERADDRESS ��'�_V_ _ CITY/STATE/ZIP CONTRACTORI✓w i El _ ` PHONE 0r7 "At f If CONTRACTOR ADDRESS cam. 4? �Z�SOh •-- _ _ CITY/STATE/ZIP LICENSE ❑*42 ❑ C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: It GEOGRAPHICAL INFORMATION: Coordinates X __ Y 1 ! PERC TEST # BUILDING PERMIT # - LAND USE APPLICATION #_ TYPE OF WORK: NEW INSTALLATION REPLACEMENT — OUT -OF -SERVICE SEPTIC SYSTEM ENGINEER DESIGNED/ALTERNATIVE DESTRUCTION INSTALLATION WILL SERVE: - RESIDENCE [ I COMMERCIAL LI OTHER NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS:. NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG. ❑ GREASE TRAP TYPE/MFG Amount Re i ted DISTANCE TO NEAREST: WELL IVO , ❑ LIFT STATION SIZE TYPE OF PUMP CAPACITY gal # OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS .I dI ft FOUNDATION ft PROPERTY LINE .30 ft ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES _l LEACHING CHAMBERS _ # OF LINES ]C 00 LENGTH OF LINES ft A4P�r � DISTANCE TO NEAREST WELL �® _ ft FOUNDATION �S— ft PROPERTY LINE .i0 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 Pip^f_ rr ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE % W Mid/% ft ❑ SUMPS WIDTH ft LENGTH _ ft DEPTH !°A 17 • _ It DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH EAn�'9QUINn.... ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY k�T ft (� SEEPAGE PITS NUMBER -2 WIDTH � *aft ft DEPTH S y TM6 ft DISTANCE TO NEAREST WELL /,SO • ft FOUNDATION �0 ' ft PROPERTY LINE J4/ 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. ADVA SIGNED Application Accepted By Final Inspection By >,� Character of Soil to Depth W33 Ft: COMMENTS M-� TITLE DATE %C� �I•"J DEPARTMENT USE ONLY Date-- -- ---- Area Employee ID#� Date F]SPECIAL PERMIT -Approved by PiU*ip Soil Character: PE SC INFO Received By- Che ash Amount Re i ted Date Permit/Code Service Request # Invoice # Permit ID# Mu 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 r