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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT ?/'k SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE[ JOB ADDRESS �� 4t CITY/ZIP Z CROSS STREET IG/�iL4 APN v PARCEL SIZE OWNER NAME A,N L r I C PHONE OWNER ADDRESSff- DEPTH ft , Q / + �e- CITY/STATE/ZIP �C�n / �! CONTRACTOR_ QI� G �C� PHONE CIE? I CONTRACTOR ADDRESS / [� ��r/Va �-1-J / CITY/STATE/ZIP LICENSE 1 1 C-42 I I C-36 OTHER A NUMBER EXPIRATION DATE 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: el RESIDENCE ] COMMERCIAL LJ OTHER NUMBER OF LIVING UNITS: L NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: If SEPTIC TANK TYPE/MFG (QN&j*j "C : 7Z CAPACITY /6)(30 gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS 1 DISTANCE TO NEAREST: WELL 0 ft FOUNDATION ft PROPERTY LINE 141 1 ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS Received # OF LINES, LENGTH OF LINES ft / DISTANCE TO NEAREST WELL/ ft FOUNDATION ��Y 657 r 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 ft LENGTH It DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It 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. ANCE NO SIGNED Application Accepted By " Final Inspection By "- Character Character of Soil to Depth of 3 Ft: COMMENTS DATE TMENT USE OINLX Date Area Employee ID# A~ Date SP [IAL ERMIT - Approved by Pit/Sump Soil Character: PE Code Sc INFO Received Check#/ Cash Amount emitted Dat Permit/ Service Request # Invoice # Permit ID# 2 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 r