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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 GALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUEI JOB ADDRESS CITY/ZIP CROSS STREET APN _ � ..` ' i PARCEL SIZE OWNER NAME ! r � _4�'M _¢¢ ] I i. ` / _,C..'I 'j _ PF OWNER ADDRESS i�,-4.�yr� _CITYISTATE/ZIP +�1+.. 1. Y V 1 1 �+ PHONE CONTRACTOR CONTRACTOR ADDRESS _ } `� �� ! .__?`. 4 ^� Vm CITY/STATE/ZIP -_ LICENSE ❑.. C-42 ❑ C-36 OTHER _ NUMBER �. ------ EXPIRATION DATE__ - WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y FJ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: I NEW INSTALLATION X REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT [ J OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE Cl COMMERCIAL I ' OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft LJ LIFT STATION SIZE TYPE OF PUMP -LI 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 ciruGn TIT[ F ik- DATE Application Accepted By Final Inspection By Character of Soil to Depth of 3 Ft: COMMENTS Date Date Area Employee ID# [I SPECIAL SPECIAL PERMIT - Approved by Pit/Sump Soil Character: __ PE Code SC INFO Received By Check#/ Cash Amount Remitted Permit/Date Service Request # Invoice # ❑ LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINESRECEP>) DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH NOV 16_ 9047 DISTANCE TO NEAREST WELL ft FOUNDATION fY PROPERTY LINE ft _ ft DEPTH SAN JOAQUIN COIAN ❑ MOUNDED WIDTH ft LENGTH _ _ )L ENVIKONMEN'TDISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE .,EAS FH r11=PART ME# ❑ SUMPS WIDTH ft LENGTH _ e.. 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 It FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH---- ft DEPTH ft DISTANCE TO NEAREST WELL It 1-C)UNDA110N _ 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 ciruGn TIT[ F ik- DATE Application Accepted By Final Inspection By Character of Soil to Depth of 3 Ft: COMMENTS Date Date Area Employee ID# [I SPECIAL SPECIAL PERMIT - Approved by Pit/Sump Soil Character: __ PE Code SC INFO Received By Check#/ Cash Amount Remitted Permit/Date Service Request # Invoice # Permit ID# 42-01 �P ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17