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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 CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 1,:2 06 u i- G 5 V L-- —CITY/ZIP- 5 v S LV CROSS STREET SII ✓ APN Q /� - 1342- f9 & _ PARCEL SIZE l /4I� hey✓ _ % /�A1, �f /yl/C/1 b1,067 OWNER NAME er�� el/e rf / /� PHONE OWNER ADDRESS O a S SCLt � / / ft CITY/STATE/ZIP ei /B 4 � / ✓2-5al CONTRACTOR DISTANCE TO NEAREST WELL PHONE ft �D 4 �r Din �� ¢ 7 CONTRACTOR ADDRESS _ / G / / CITY/STATE/ZIP LICENSE re C-42 D C-36 OTHER NUMBER EXPIRATION DATE .ZO WATER TABLE DEPTH: - L' ft GEOGRAPHICAL INFORMATION: Coordinates X Y 1 PERC TEST # Ir BUILDING PERMIT # — LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION R AIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMEN OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION 9 01 INSTALLATION WILL SERVE:RESIDENCE ❑ COMMERCIAL OTHER DO NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYE S: LY SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE TYPE OF PUMP CAPACITY 1,o7 -P0— gal # OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS ft FOUNDATION ft PROPERTY LINE ft ❑ PKG TX PLANT ❑ 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 THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. SIGNED TITLE //L><vlts:lZ DATE Application Accepted By Final Inspection By Character of Soil to Depth of COMMENTS '�; DateArea y Date % 11 SPE Pit/Sumo Soil Character: Employee ID# A&"f- PERMIT -Approved by PE Code LEACH LINES LEACHING CHAMBERS Amount ate Remitted Permit/ Service Request # # OF LINES LENGTH OF LINES S ft I DISTANCE TO NEAREST WELL b1,067 ft FOUNDATION ft PROPERTY LINE 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 LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH It LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft SEEPAGE PITS NUMBER r WIDTH 2 /t ft DEPTH i- 7 / ft DISTANCE TO NEAREST WELL ASO ft FOUNDATION —ft PROPERTY LINE �fJ 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 TITLE //L><vlts:lZ DATE Application Accepted By Final Inspection By Character of Soil to Depth of COMMENTS '�; DateArea y Date % 11 SPE Pit/Sumo Soil Character: Employee ID# A&"f- PERMIT -Approved by PE Code SC INFO Receivek#/ B ash Amount ate Remitted Permit/ Service Request # Invoice # Permit ID# I --,0 �, b1,067 q.7 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17