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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P ✓' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CROSS STREET OWNER NAME_ OS�-APN CITY21P lbo- v PARCEL SIZE . ., f it PHONE OWNER ADDRESS ✓AA/ 6 CITY/STATE/ZIP �q n CONTRACTOR L(fJ /I Ir�.j �Jj jJ PHONE ,;O CONTRACTOR ADDRESS �S V/SQA �r- CITY/STATE/ZIPy"G'•� ('1 �j/�� LICENSE ❑CX -42 I C-36 OTHER NUMBER a J EXPIRATION DATE l WATER TABLE DEPTH: o ft GEOGRAPHICAL INFORMATION ❑ PERC TEST # BUILDING PERMIT # TYPE OF WORK: NEW INSTALLATION REPAIR/ADI Coordinates X Y_ LAND USE APPLICATION # IN ENGINEER DESIGNED REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION , INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: UMBER OF BEDROOMS: NUMBER OF EMPLOYEES: XSEPTICTANK TYPE/MFG CAPACITY /CDC) gal # OF COMPARTMENTS L3 GREASE TRAP TYPE/MFG CAPACITY ` gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE 2,0 ft ❑ LIFT STATION SIZE TYPE OF PUMP O PKG TX PLANT O SAND OIL SEPARATOR (ENCLOSED SYSTEM) 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 THAI I AM IN COMPLIANCE WITH ALL WORKERS COMPEN�ION LAWS. MINIMUM HOUR ADVANCE 410TICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 D SIGNED_ :z;`- _ TITLE---1D12�/fi!_r^ DATE 5 T w EPARTMENT U E O 7 L, Application Accepted By Date Area Employee ID#� Final Inspection By Date ❑ SPECIAL PERMIT - Approved by Character of Soil to Dep of Ft 01 Pit/Sump Soil Character: COMMENTS PE Code LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES 400 /r ft Permit/ Service Request # Invoice # DISTANCE TO NEAREST WELL(90 ft FOUNDATION �' 9-10ft PROPERTY LINE 'Q'� !7 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 FQUNDATION 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' ft PROPERTY LINE ft y Ids SEEPAGE PITS NUMBER 3 WIDTH �� FOUNDATION ft DEPTH d-2457 ft DISTANCE TO NEAREST WELL �Q'�O ft FOUNDATION SCJ ft PROPERTY LINE 0 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 THAI I AM IN COMPLIANCE WITH ALL WORKERS COMPEN�ION LAWS. MINIMUM HOUR ADVANCE 410TICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 D SIGNED_ :z;`- _ TITLE---1D12�/fi!_r^ DATE 5 T w EPARTMENT U E O 7 L, Application Accepted By Date Area Employee ID#� Final Inspection By Date ❑ SPECIAL PERMIT - Approved by Character of Soil to Dep of Ft 01 Pit/Sump Soil Character: COMMENTS PE Code SC INFO Received By Check#/ Amount Cash Remitted Date Permit/ Service Request # Invoice # Permit ID# Op � S D 179/ 7 3 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17