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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 -REFUND BL ERMIT FALL 209 953-7697 FOR INSPECTION EXPIR S 1 YEAR DATE ISSUEI JOB ADDRESS % �� CITY/ZIP�� CROSS STREE sc J _ APN nZAD —n44 � PARCEL SIZE � 6 OWNER NAMEwk I 1 �J PHONE6152 972.6 OWNER ADDRESS CITY/STATE/ZIP 9 S CONTRACTOR 6►,-_ILNy PHONE CONTRACTOR ADDRESS 7VLJW -4N-CITY/STATE/ZIP 1 LICENSE IAC -42 El. 'C-36 OTHER A NUMBER (Mnl5)EXPIRATION DATE L WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: ❑ PERC TEST # BUILDING PERMIT # TYPE OF WORK: NEW INSTALLATION je REPAIR/ADDITI( Coordinates X Y LAND USE APPLICATION # IN ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: 11 RESIDENCE I I COMMERCIAL I OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG Check#/ Amount CAPACITY Permit/ gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG Cash Remitted CAPACITY Service Re uest # -�� gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL S6 _ ft FOUNDATION ft PROPERTY LIIp�f #d:T ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(RV ll) NOV 16 2017 ft ❑ LEACH LINES ❑ LEACHING CHAMBERS _ # OF LINES LENGTH OF LINES DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY ft ❑ FILTER BED WIDTH ft LENGTH It DEPTH ENVIRONMENTAL ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY L N ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST 2 WELL ft FOUNDATION ft PROPERTY LINE ft SUMPS WIDTH ft ENGTH O ft DEPTH It DISTANCE TO NEAREST WEL ft FOUNDATION to C ft PROPERTY LINE J + It ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE 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. Final Inspection By Character of Soil to COMMENTS 42 Depth of 3 Ft: - PwSump Soil C racter: 2 u H r� Invoice # Permit ID# PE Si Received Check#/ Amount Date Permit/ Code INFO By Cash Remitted Service Re uest # -�� S6 42-01 5/5/17 T