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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL 209/f953-7697 FOR INSPECTIONS..p+ EExPIRES�1yYEAR gFROM DATE ISSUED JOB ADDRESS �� /%/�� Gf —CITY/ZIP ! / 7 ✓ ✓ ! / CROSS STREETa�PARCEL APN PARCEL SIZE E OWNER NAME-7;j1XKS 04-, VC,� dblObOM GA.Q- PHONE '4y �— lI,WNER ADDRESS V/ CITY/STATE/ZIP 7�e c' Tl / •,t�..,iJ ��V CONTRACTOR PHONE OC 0 ? — CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE I I C-42 I I C-36 OTHER NUMBER EXPIRATION WATER TABLE DEPTH: VAf ' V ft GEOGRAPHICAL INFO TION: Coordinates X _ Y PERC TEST # BUILDING PERMIT # U120qjZj LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION R AIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEME T OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE COMMERCIAL OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG CAPACITY fWu gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG _ CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL O O ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ FILTER BED WIDTH ft LENGTH VLEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES ❑ MOUNDED DISTANCE TO NEAREST WELL—1 061 ft FOUNDATION ft PROPERTY LINE ❑ FILTER BED WIDTH ft LENGTH ft DISTANCE TO NEAREST WELL FOUNDATION ft ❑ MOUNDED WIDTH ft LENGTH DISTANCE TO NEAREST WELL ❑ SUMPS WIDTH ft LENGTH DISTANCE TO NEAREST WELL ❑ DISPOSAL PONDS WIDTH ft LENGTH DISTANCE TO NEAREST WELL ❑ SEEPAGE PITS NUMBER WIDTH DISTANCE TO NEAREST WELL ft FOUNDATION DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH _ft PROPERTY LINE ft DEPTH 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. REQUIRED FOR INSPECTIONS - ` EPARTMENT _SE N Y Application Accepted By Date ` Area Employee ID# Final Inspection By tiv4 Date LlSPE TPRMIT - Approved by 1 Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS ft ft ft ft ft ft ft ft ft ft ft ft tt ft FOUNDATION ft ft FOUNDATION ft ft FOUNDATION ft ft FOUNDATION ft FOUNDATION DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH ft PROPERTY LINE DEPTH _ft PROPERTY LINE ft DEPTH 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. REQUIRED FOR INSPECTIONS - ` EPARTMENT _SE N Y Application Accepted By Date ` Area Employee ID# Final Inspection By tiv4 Date LlSPE TPRMIT - Approved by 1 Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS ft ft ft ft ft ft ft ft ft ft ft ft 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 T, J+ O 0 PE Code SC INFO Received By,7, ec ash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 4V L Cly 7 9 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 T, J+ O 0