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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-REFUNDABLE PERMIT l GA JOB ADDRESS 7/<—V <— tXPIRES l YEAR FROM DATE ISSUE CROSS STREET // ,% / //�,%I /l A P N DSJ :V Z PARCEL SIZE ) OWNER NAME !1� _ PHONE -21 OWNER ADDRESS 9�h Y �// 1�� / CITY/STATE/ZIP CONTRACTOR l [ -K,, PHONE CONTRACTOR ADDRESS -CITY/STATE/ZIP/////� jzt �j>/t� LICENSE 'x IC -42 CInC-36 OTHER- NUMBER EXPIRATION DATE WATER TABLE DEPTH:(" � I �V — ft GEOGRAPHICAL INFORMATION: Coordinates X Y [. PERE 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 [I COMMERCIAL I 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 gal # OF COMPARTMENTS CAPACITY _ gal # OF COMPARTMENTS ft FOUNDATION ft PROPERTY LINE ft _ ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) TLh LEACH LINES ❑ LEACHING CHAMBERS # OF LINES LENGTH OF LINES / ft / DISTANCE TO NEAREST WELL _- ft FOUNDATION / �� ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL fl FOUNDATION ft, PROPERTY LINE It ❑ 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 WIDTH It DEPTH : 57:� ft DISTANCE TO NEAREST WELL_ r ft FOUNDATION ft PROPERTY LINE It 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 COM//PJJENShT N LAWS. MINIM�IM OUI,ADVATVCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 _ SIGNED �� / moiTITLE. // DATE -D PARTMENT (ISE ON14Y Appli ation Accepted By Date_ _ rea _ Employee ID#� Final Inspection By Date___? SPECIAL PERMIT -Approved by Character of Soil to Dept of 3 Ft; _ ___ --Pit/Sum Soil Character: COMMENTS _ _--- PE SC Received Check#/ Amount Date Permit/Code Invoice # Permit ID# INFO B Cash Remitted Service Request # 0 l (g y Za 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 T