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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAgUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELYON AVENUE - STOCKTON CA 95205 - (209) 468-3420 _,JON -REFUNDABLE PEFWJT CAL 209 953-7697 FOR INSPECTIONS EXPIRES 1�Y,E/AR FROM DATE ISSUED JOB ADDRESS G� ! �' CITY/ZIP C�`I ar � / + CROSS STREET APN PARCEL SIZE OWNER NAME /4" ' % PHOINC � �/� OWNER ADDRESS /�" CIC/ , CITY/STAT IP � Cli � CONTRACTOR MGG ��* i PHONE�� CONTRACTOR ADDRESS Z!�57 Lar,' b, CITY/STATE/ZIP Gcjc� it 9 Sty/ LICENSE I C-42 I I C-36 OTHER ot— NUMBER Z U EXPIRATION DATE C- ?, WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y _I PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESI NED /ALTERNATIVE Permit/Code REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL I OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG CAPACITY boogal # OF COMPARTMENTS !� ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS r DISTANCE TO NEAREST: WELL 100 ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) t LEACH LINES LEACHING CHAMBERS _ # OF LINES LENGTH OF LINES ft n 1 t DISTANCE TO NEAREST WELL V U ft FOUNDATION �'� ft PROPERTY LINE 7 r 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 ft 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 ft PROPERTY LINE ft SEEPAGE PITS NUMBER �7 WIDTH Ir ft DEPTH /LS ft DISTANCE TO NEAREST WELL ft FOUNDATION td I ft PROPERTY LINE T 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 ITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPEN ON LAWS. MINIM DVANCE NOTICE REQUIRED FOR IN ECTIONS - PLEASE CALL 209 9553-7697 SIGNED TITL_ DATE Application Accepted By Final Inspection By Character of Soil to Dept f 3 COMMENTS�� —/A 7, L-A f! EPARTME NTUSE Nt Y i Date r! Area Employee ID# Date SPE IAL PERMIT - Approved by Pit/Sump Soil Character: PE SC Received Check#/ Amount Date Permit/Code Invoice # Permit ID# INFO B Cash Remitted Service Request # O s (Z�b79/0 Old Ta,4uF ,U lel-V'r rOYeSP�— b!a1 (2 / t' � L.i 5 5//17 '� % 1--I % � / 6 � � �� ,�j ONSITE WASTEWATER TRT T SYSTEM PERMIT