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a ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 'NON-HEFUNDABLE PERMIT (:ALL K0 953 7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE I OB ADDRESS �I C. CITY21P Seo R;, SS STREET ^ /�� Q �cft , Vk ! '� ' APIN ' `3 o I PPA�RCEL SIZE KWNER NAME S ./� l r ► v erzCl� T�1`1 '�/� yi¢ PHONE �IRIVNER ADDRESS ��( r 6 CITY/STATE/ZIP �JJJ 'r l� %QNTRACTOR /93W �/ WELL It C, J�� PHONE ❑ i WIDTH ft LENGTH ADDRESS LICENSE I I C-42 I I C-36 OTHER CITY/STATE/ZIP NUMBER EXPIRATION WATER TABLE DEPTH: ' rl CD ft GEOGRAPHICAL INFORMATION: Coordinates X ❑ PERC TEST # BUILDING PERMIT # y i Z LAND USE APPLICATION # of TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DI Y TERNATIVE k REPLACEMENT 4:fA A �� OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION -16 (A )C - INSTALLATION WILL SERVE: RESIDENCE Il COMMERCIAL C OTHER NUMBER OF LIVING UNITS: i 4 NUMBER OF BEDROOMS: U NUMBER OF EMPLOYEES: SEPTIC TANK ❑ GREASE TRAP ❑ LIFT STATION TYPE/MFG`fi_ _ CAPACITY TYPE/MFG CAPACITY DISTANCE TO NEAREST: WELL � Ui1 t It FOUNDATION SIZE TYPE OF PUMP ❑ PKG TX PLANT 5 7 0 gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ 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 Application Accepted By Final Inspection ByA Character of Soil to Dept COMMENTS A w, 'OR INSPECTIONS - PLEASE CALL 209 9U -Z&97 97 TITLEYCS.-S1 DATE d-1 2 r DEPARTMENT USE ONLY U - Date IL-11-lf Area Employee ID# / Date 40; 7 ❑ SPECIAL PERMIT - Approved by L IUSump Soil Character: PE Code LEACH LINES LEACHING CHAMBERS Check#/ as # OF LINES LENGTH OF LINES 6's ft Date Permit/ Service Request # DISTANCE TO NEAREST WELL ),idh L It FOUNDATION i 0 4 ft PROPERTY LINE S a' ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE It ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It 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 ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH 3 , ft DEPTH ft DISTANCE TO NEAREST WELLS ft FOUNDATION ii -I ft PROPERTY LINE S .) 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 Application Accepted By Final Inspection ByA Character of Soil to Dept COMMENTS A w, 'OR INSPECTIONS - PLEASE CALL 209 9U -Z&97 97 TITLEYCS.-S1 DATE d-1 2 r DEPARTMENT USE ONLY U - Date IL-11-lf Area Employee ID# / Date 40; 7 ❑ SPECIAL PERMIT - Approved by L IUSump Soil Character: PE Code SC INFO Received By Check#/ as Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 1