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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT j JOB ADDRESS / U CALL 209) 953-7697 FOR INSPECTIONS CROSS STREET APN OWNER NAME-s>�HCI OWNER ADDRESS EXPIRES 1 YEAR FROM 12ATE ISSUEI �� V PARCEL SIZE CONTRACTOR�L (�Lj�!$PO/Ci}7/6^r' PHONE 1L� AF3 ,A Q CONTRACTOR ADDRESS vlr-v [ /1VVg5 �l1 `CITY/STATE/ZIP �/✓GD/Ly� 644 / r26 LICENSE 36 OTHER /J` NUMBER EXPIRATION DATE C-42 L C _ �Y / WATER TABLE DEPTH: _ _. ft GEOGRAPHICAL INFORMATION: Coordinates X __ Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: I NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM i1 DESTRUCTION SJz� %/C ��< INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL FI OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK ❑ GREASE TRAP ❑ LIFT STATION TYPE/MFG TYPE/MFG DISTANCE TO NEAREST: WELL SIZE TYPE OF PUMP CAPACITY CAPACITY ft FOUNDATION ❑ PKG TX PLANT gal # OF COMPARTMENTS gal # OF COMPARTMENTS It PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS _. Check#/ Cash # OF LINES Date LENGTH OF LINES Invoice # DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ FILTER BED WIDTH It LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ MOUNDED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH It LENGTH ft DEPTH DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE ❑ DISPOSAL PONDS WIDTH It LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH DISTANCE To NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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. AEMMM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 9� SIGNED ` - TITLE �- R(/ . /t1Ct Ge/lP DATE / DEPARTMENTIUSK ONLY Application Accepted By Date Area Employee ID# Final Inspection By Date / ❑ S ECIAL PERMIT - Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS ft It It ft It It It It It ft ft It PE Code SC INFO Received Ily Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 42-01 W T�, q ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 r