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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL1209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS �7 -?U ,d- r -e 1 r7e-V I yj CITY/ZIP 11 PERC TEST # CROSS STREET I� ✓�� I� L'tJ�(� APN PARCEL SIZE BUILDING PERMIT # LAND USE APPLICATION #rkr i (1 0 C I- OWNER NAME O 1 %C tQ PHONE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION E O UN; U Apr OWNER ADDRESS CITY/STATE/ZIP /'' // �'� o NUMBER OF LIVING UNITS: MS: NUMBER OF BEDROONUMBER OF EMPLOYEES: CONTRACTOR i�/f�� a� �j r7 VI � I -tel o�.✓/ PHONE � /j^ � � / ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS hh� CONTRACTOR ADDRESS �2[ � �l✓ON (/✓ CITY/STATE/ZIP C��i (� �� 62 75- LICENSE _I-42 1 1 C-36 OTHER NUMBER 7S EXPIRATION DATE ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) WATER TABLE DEPTH:r ft GEOGRAPHICAL INFORMATION: COordl teS X Y 11 PERC TEST # hec s BUILDING PERMIT # LAND USE APPLICATION #rkr i (1 TYPE OF WORK: NEW INSTALLATION REPAIR/AUDITION ENGINEER DESIGOWP&A8NANV`,E Invoice # REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION E O UN; INSTALLATION WILL SERVE: KIRESIDENCE LI COMMERCIAL 11 OTHEROEPARTME NUMBER OF LIVING UNITS: MS: NUMBER OF BEDROONUMBER OF EMPLOYEES: � SEPTIC TANK TYPE/MFG /W CAPACITY AcQQO gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS 62 75- DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) __.......................... ---...._.____._.._ ----------- W .__ LEACH LINES LEACHING CHAMBERS # OF LINES :5 LENGTH OF LINES 85 ft LEACH DISTANCE TO NEAREST WELL- ft FOUNDATION Z O ' ft PROPERTY LINE CILO , ft ❑ FILTER BED WIDTH It 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 ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft SEEPAGE PITS NUMBER WIDTH /Il8 " It DEPTH 1?s ' ft DISTANCE TO NEAREST WELL �.�Q / ft FOUNDATION Of .36 ft PROPERTY LINE SO 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. MINIMUM 4g HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE_ et4ke4 DATE �j -ay-(g Application Accepted Elyy Final Inspection By Character of Soil to Depth of 3 Ft: COMMENTS PARTMENT SE O L i/ Date Area q?q Employee ID# Date�k ElSPECIAL PERMIT - Approved by PiUSump Soil Character: . w N PE Code SC INFO Received B hec s Amount Date Remitted Permit/ Service Request # Invoice # Permit ID# goo 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17