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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT v" SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 LYON -REFUNDABLE FERMII ,JOB ADDRESS CROSS STREET GALL (209) 953-7697 FOR INSPECTIONS ,�IR�ESS 1 YEAR FROM DATE IIS]SUE CITY/ZIP // I/L M <Cd7 �1 —:;p —1 APN(/ ' /!i �/ t� PARCEL SIZE OWNER NAME �V _ _ PHONE OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR / iii./�- L C,� _ PHONE 7S -SK S j ]� CONTRACTOR ADDRESS /Gl C/ �1fiAJ IJ. e—W / CITY/STATE/ZIP /&J C4. LICENSE I I C-42 I C-36 OTHER NUMBER S EXPIRATION DATE WATER TABLE DEPTH: �V ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION owr REPAIR/ADDITION ENGINEER DESI ED/ALTERNATVE REPLACEMENT J OUT -OF -SERVICE SEPTIC SYSTEM sfF DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL E OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ® SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE TYPE OF PUMP CAPACITY (00 y gal # OF COMPARTMENTS__ CAPACITY gal # OF COMPARTMENTS ft FOUNDATION ft PROPERTY LINE ft ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES I' LEACHING CHAMBERS # OF LINES LENGTH OF LINES DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ FILTER BED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ MOUNDED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION 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. ADVANCE SIGNED Application Accepted By Final Inspection By Character of Soil to depth of 3 Ft: COMMENTS DATE 2- Z .D PARTMENeUSEA�fALY Date Area Employee ID# Date ❑ SPECIAL PERMIT - Approved by Pit/Sump Soil Character: ft ft ft ft ft ft ft ft ft ft ft ft PE Code SC INFO Received Ev Cash Amount Re fitted Date Permit/ Service Request # Invoice # Permit ID# I W J Ll 75 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17