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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQU'?d COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 IVUN-hSEFUNDABLE PERMIT G L ZUJ Yb3-/b5/ FOR INSPECTIONS tXPIRES 1 YEAR FRO UATE ISSUE JOB ADDRESS PILPO tAj Uat '7CITY/ZIP � SP zt CROSS STREETW APN�' / f� PARCEL SIZE OWNER NAME � �-� L PHONE OWNER ADDRESS � `� v *a_u: CITY/STATE/ZIP~ CONTRACTOR,O) ��% �I �qqL w -c> ,1 �A �'7 2 �^�' rf-� PHONE �� C CONTRACTOR ADDRESS �3 1 �}*�'^'lti-�- CITY/STATE21P !_23r ' S - •�Z a� nn '' P} I i iv (o LICENSE 1 C-42 I C-36 OTHERC-7-4 NUMBEf�j� � 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: LI RESIDENCE ❑ COMMERCIAL LI OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK ❑ GREASE TRAP ❑ LIFT STATION TYPE/MFG TYPE/MFG DISTANCE TO NEAREST: WELL SIZE TYPE OF PUMP CAPACITY CAPACITY It FOUNDATION ❑ PKG TX PLANT ❑ LEACH LINES LEACHING CHAMBERS Received Bly ec as # OF LINES Date DISTANCE TO NEAREST WELL Permit ID# It FOUNDATION ❑ FILTER BED WIDTH ft LENGTH 65 DISTANCE TO NEAREST WELL ft FOUNDATION ❑ MOUNDED WIDTH ft LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION ❑ SUMPS WIDTH ft LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION ❑ DISPOSAL PONDS WIDTH ft LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION ❑ SEEPAGE PITS NUMBER WIDTH DISTANCE TO NEAREST WELL ft FOUNDATION E gal # OF COMPARTMENTS gal # OF COMPARTMENTS It PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LENGTH OF LINES ft ft PROPERTY LINE It ft DEPTH ft ft PROPERTY LINE ft ft DEPTH w_ /q%Ae1.ft It PROPERTY LINEft ft DEPTH ft ft PROPERTY LINE ft ft DEPTH SAN JIc UILY ft ft PROPERTY/14�J 1vti/R�� CO(/ ft ft DEPTH O'PART ft 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. NIMUM HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL 209 953-7697 �qc�� _zip -1 ira- SIGNED TITLE DATE Application Accepted By Final Inspection By Character of Soil to De I of COMMENTS %� DEPARTMENTUSE LY Date Area Employee ID �- Date ❑ SPECIAL PERMIT - Approved by Pit/Sump Soil Character: 'r- I - - R -e_ PE Code SC INFO Received Bly ec as Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# S'zS400-76AI 65 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 T