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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 SC INFO GALL (ZU,9) 953-7697 FOR INSPECTIONS EXPIRES 1 YE R FROM UATE ISSUE JOB ADDRESS 3 V S u, --CITY/ZIP f k r✓ ^ CROSS STREET `1V ` h I' V,/ -- .l /'� APN /O � -/2 " /] y PARCEL SIZE e (�1 I tV • \ CL `�`� ��i OWNER NAME �/ V� F-� Y _ _ PHONE- OWNER ADDRESS U'�/ C.L CITY/STATE/ZIP `f C Y\/- CONTRACTOR/ PHONE CONTRACTOR ADDRESS LICENSE 1 1 C-42 F] C-36 OTHER CITY/STATE/ZIP NUMBER EXPIRATION WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y LJ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION , REPAIR/ADDITION ENGINEER DESK REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION NED/ALTERNATIVE INSTALLATION WILL SERVE: LI RESIDENCE ❑ COMMERCIAL U OTHER NUMBER OF LIVING UNITS:. _ I 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 ft FOUNDATION ❑ PKG TX PLANT gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ FILTER BED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ MOUNDED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SUMPS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ SEEPAGE PITS NUMBER WIDTH It DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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 COMPENqATION LAWS. MIINIM� USM HOUR ADVANCE TICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED ►VAX-�"� �D TITLE DATE , D d ` _ p p COMMENTSCJI�e✓%ed ltie ln�/e_ y ,HYLA o Y7 'VI 01 � ►�- ti-orv� � ft ft ft ft ft ft ft ft ft ft ft ft PE Code SC INFO Received B Check#/ as Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 42-01` L O 7�0 �(O ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17