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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 Nou-REFUNDABLE PERMIT 433 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS ./ CITY/ZIP �% n CROSS STREET Mat Ar T^JJ N � - APN ;Y9-4;60 -02-- PARCEL SIZE � o OWNER NAME 9? { PHONE OWNER ADDRESS c/d✓ 11�oel*so9to /[� �//� 1 CITY/STATE/ZIIPP�J-, ;r 'l? e CONTRACTOR Com' v/`.�/!J JVJ` —PHONE Q1_/_LJ"r l '/, CONTRACTOR ADDRESS �(� .YJ �/� �G C.� C+ CITY/STATE/ZIPf37 LICENSE I C-42 LI C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL IN ❑ PERC TEST # BUILDING PERMIT # ates X Y LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESH REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION NED/ALTERNATIVE INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER FOUNDATION ft PROPERTY LINE ft NUMBER OF LIVING UNITS: 2AA? NUMBER OF BEDROOMS: lze NUMBER OF EMPLOYEES: # OF LINES_ LENGTH OF LINES _ ft SEPTIC TANK TYPE/MFG Pf CAPACITY �9O L— gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS SIGNED TITL DATE DEPARTMENTD LY✓��`j��_(�� Application Accepted Sy Date %Area ,� ` _ ' Employee ID# Final Inspection By Date 3 l0 ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 F . Pit/Su Soil Character: COMMENTS PE Code SC INFO DISTANCE TO NEAREST: WELL O f It FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LEACH LINES LEACHING CHAMBERS _ # OF LINES_ LENGTH OF LINES _ ft • DISTANCE TO NEAREST WEL OU 'E" It FOUNDATION f ft PROPERTY LINE I 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 LINEN Via ft ' El SUMPS WIDTH ft LENGTH In ft DEPTH • ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH AN ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPEWgY#I E va O� ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH /N6 ft DISTANCE TO NEAREST WELL ft FF��Etil'- FOUNDATION ft PROP RI "4�71IWE NM NTej 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. SIGNED TITL DATE DEPARTMENTD LY✓��`j��_(�� Application Accepted Sy Date %Area ,� ` _ ' Employee ID# Final Inspection By Date 3 l0 ❑ SPECIAL PERMIT - Approved by Character of Soil to Depth of 3 F . Pit/Su Soil Character: COMMENTS PE Code SC INFO Received Bv Chec ash Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17