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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT f ✓ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT E;ALL 8 1� 1 ( ✓N y� R JOB ADDRESS CAPACITY gal t'CZ.Z FILTER BED WIDTH DISTANCE TO NEAREST: WELL _�_ Mf',(. ft FOUNDATION � ft CROSS STREET ITw Y cgQ y SIZE TYPE OF PUMP _ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ MOUNDED WIDTH OWNER NAME ft DEPTH u 0-� r WELL ft FOUNDATION ft PROPERTY LINE ft] OWNER ADDRESS SUMPS WIDTH _ ft LENGTH C(%,NTRACTOR ['CLt4^ LI= -I, CONTRACTOR ADDRESS QO P!n?'i' I2'') LICENSE ❑ 'C-42 ;C-36 OTHER CITY/ZIP APN /1(" i SIZE �1sd�J PHONE 2,d,i' 4a i -3Vj't l CITY/STATE/ZIP L �`^ �� h r( ✓3 / �!/ PHONE `2.O a - Lt C I CITY/STATE/ZIP _ NUMBER I 130 4Lk EXPIRATION DATE ` � t-0' t WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATION: Coordinates X Y I❑ PERC TEST # BUILDING PERMIT #•" ( LAND USE APPLICATION #_ TYPE OF WORK: NEW INSTALLATION I I REPAIR/ADDITION ENGINEER DESK L1 REPLACEMENT C I OUT -OF -SERVICE SEPTIC SYSTEM I I DESTRUCTION _ NED/ALTERNATIVE INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: -p- SEPTICTANK TYPE/MFG 12-00�� CAPACITY L ZOo gal #OFCOMPARTMENTS Z ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS FILTER BED WIDTH DISTANCE TO NEAREST: WELL _�_ Mf',(. ft FOUNDATION � ft PROPERTY LINE ft 6!1 ❑ LIFT STATION SIZE TYPE OF PUMP _ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) 1 LEACH LINES ❑ LEACHING CHAMBERS# OF LINES 7- LENGTH OF LINES ScS (( ft he Cash DISTANCE TO NEAREST ''��II\\ WELL� ft FOUNDATIONOf t -ft PROPERTY LINE '�/7 it ❑ FILTER BED WIDTH ft LENGTH it DEPTH ;t� vt192ait DISTANCE TO NEAREST WELL it FOUNDATION _ ft PROPERTY LINE ❑ MOUNDED WIDTH ft LENGTH ft DEPTH u 0-� DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft] ❑ SUMPS WIDTH _ ft LENGTH f ft DEPTH lit DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE JOAQUIN ft ❑ DISPOSAL PONDS WIDTH ft LENGTH y ft DEPTH IEA ONME� ft' DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE T�ENfi' SEEPAGE PITS NUMBER _ WIDTH 3 C•, it DEPTH 2 , o ft /\ DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE C / 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. SIGNED 'VA IIYJrGL+1IV/YJ - rLGH JC VHLL LU' 'JJ -/U'/ TITLEDATE DEPARTMENTIUSEIONLy Application Accepted By `.. Date//// _.77 Area Employee ID/J/6;_ Final Inspection By `L""Y Date / tY ❑ SPECIAL PERVIT - Approved by Pit/Sump Soil Character: S4 Character of Soil to Depth of 3 Ft: �` / eo,"e— ENCS �Z / S c PE SC INFO Received B he Cash Amount Remitted D to Permit/Code Service Request # Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 T