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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-REFUNDAaLZ AERINT , -CALL W) 953.7697 FOR INSPECTIONS, .� EXPIRES 1 YEA�LFWAA DDAWSSUED JOB ADDRESS CROSS STREET OWNER NAME_ OWNER ADDRE CONTRACTOR ' APN V32 ` r ou —',_o ,^ PARCEL SIZE • 0 Q CONTRACTOR ADDRESS I L \JV 1tr CITY/STATE/LIP _ LICENSE VA C-42 ❑I 'C-36 OTHER NUMBER ito 15 � EXPIRATION DATE WATER TABLE DEPTH:, t �/, 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 K COMMERCIAL U OTHER _ Che Cash NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: Permit/ Service Request # Invoice # Permit ID# El SEPTICTANK TYPE/MFG CAPACITY Qal # OF COMPARTMENTS Z 4 �531)CITY 5go3 ❑ GREASE TRAP TYPE/MFG"— f _ gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP _ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LEACHI CHAyyM��BE��''R_S �_r _ # OF LINES LENGTH OF LINES f ft DISTANCETV''1�9 L4WELL 5w't FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH It LENGTH _ ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ MOUNDED WIDTH It 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 It ❑ DISPOSAL PONDS WIDTH _ ft LENGTH _ ft DEPTH It DISTANCE TO NEAREST WELL _ It FOUNDATION ft PROPERTY LINE ft 7.0 SEEPAGE PITS NUMBER VIDTH ft DEPTH ft DISTANCE To NEAREST WE 1_(_ FOUNDATION 10 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. rml" HOW A4QVrfFaNQT REQUIRED FOR TI ASE CALL 209 -76 SIGNED '�LUX—)TITLEENAMWIV I DATE , +11 I-: L 1 S CA*tZ-- "TC) 0.6, I7� tic 1 'ate" rwr_ foo DQ 44 PAY MEN r RECEIVE QP i IAR 16 2Q, M e p,yt SAN JOAQUIN cnl i _D PARTMENT E ONLY Hr_ALTHDEPP„<iltC':: t1 Application Accepted B*,ofF Date__ _ Area Employee ID#_� AC ov sinal Inspection By Date b U SP IAL PERMIT - Approved by Character of Soil to a ____ Pit/Sump Soil Character: C. MMENTS 42 .4 .V � r c. PE Code SC INFO Received B _ Che Cash A ount Remitted Date Permit/ Service Request # Invoice # Permit ID# (,p 5go3 �- 42-01• ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 r,