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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P USAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT JOB ADDRESS CROSS STREET OWNER NAME OWNER ADDRESS CONTRACTOR n' A,�' CONTRACTOR ADDRESS 'V l.-I�� LICENSE El/ *42 [I OC -36 OTHER CALL 209 953-7697 FOR INSPECTIONS dr.' __ ___ CITY/ZIP APN s tXPIRES 1 -YEAR FROM UATE ISSUEI PARCEL SIZE CT�EITY/STATE/ZIP ( 1 ✓KJ OPHONE 4A CITY/STATE/ZIP NUMBER V I EXPIRATION DATE 1� _ WATER TABLE DEPTH: `-('oo' li " ft GEOGRAPHICAL INFORMATION: Coordinates X Y ec ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # Permit ID# TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION 1 1 ENGINEER DE GN D/ RNATIV �-- s ❑ REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM -;00" DESTRUCTIO INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIA ❑ OTHER y NUMBER OF LIVING UNITS: 1 NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: VII SEPTIC TANK TYPE/MFG ` CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG TTT CAPACITY gal # OF COMPARTMENTS -7 DISTANCE TO NEAREST: WELL ft FOUNDATION -�$ It PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) 5 4 LEACH LINES i& LEACHING CHAMBERS , # OF LINES LENGTH OF LINES ft n I DISTANCE TO NEAREST WELL 100 ft FOUNDATION 1 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 ft SUMPS WIDTH ftj�p1 ft, DEPTH fl 4 DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE � ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ISAIKy ft DISTANCE TO NEAREST WELL ft FOUNDATION ftF�j7^F.^��Y� i ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH It DISTANCE TO NEAREST WELL ft FOUNDATION ft RrY LINE ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BES�I ACCOXNCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIF�VR��D LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND TH ,IWAi< CE WITH ALL WORKERS COMPENSATION LAWS. EP'4arMEIVT. Application Accepted By Final Inspection By tS�QP-U� Character of Soil to Depth of 3 Ft: COMMENTS t+r DEPARTMENT USE ONLY Date t> ' / 1 Area Employee ID# d n Date %-3�Zcuzl ❑ SPECIAL PERMIT - Approved by Pit/Sump Soil Character: C14!x� i 11 ; PE Code Received B ec Amount Remitted Da Permit/ Service Request # Invoice # Permit ID# �z� u EFO �-- s 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 r