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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-HEFUNDABLE PERMIT I GALLZU.9 VbZ1-/b5/ FOR INSPECTIONS` tXPIHES 1 TEAR FHOM UAI E 1551,1EI JOB ADDRESS # OF LINES act_ CITY/ZIP J LENGTH OF LINES CROSS STREET — _ _ APIN D�+Q 1/ ZN) ` PARCEL SIZE OWNER NAME OWNER ADDRESS / -- -- -- �I� CITY/STATE/ZIP PHONE sxK gsZ �s 3-I y y rl ►'1G ft CONTRACTOR 6� PHONE LENGTH CONTRACTOR ADDRESS LICENSE ❑'i C-42 ❑I C-36 OTHER TE/ZIP _- NUMBER — EXPIRATIONDATE_ — WATER TABLE DEPTH. ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE 1-1 COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: ?% NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG L ' CAPACITY boo gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG r� CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL M8 OU66�,"V ft FOUNDATION S' ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS Received Check#/ Amount # OF LINES Permit/ LENGTH OF LINES ft Code DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL it FOUNDATION it PROPERTY LINE It ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH it DEPTH ft DISTANCE TO NEAREST WELL it FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 I Application Accepted B Final Inspection By &4w Character of Soil to Depth of 3 Ft: COMMENTS Date -PLEASE TITLE LL 209 953x707 DATE Z S l i, II J Area Employee ID# /✓t� 1.1 SPECIAL PERMIT - Approved by Pit/Sump Soil Character: PE SC Received Check#/ Amount Date Permit/ Invoice # Permit ID# Code INFO Lz Xia_9_0�Remitted Service Request # 42.01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17