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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAOUIN COITNTY 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 f CITY/ZIP CROSS STREET APN:ga�PARCEL SIZE✓J OWNER NAME V,n hJ I i AI5 ILL P�5 PHONE 7l S- 36XS- -257,+S OWNER ADDRESS 91rfl� CITY/STATE/ZIP CONTRACTOR �7y� PHONE CONTRACTOR ADDRESS LICENSE I I C-42 ! 1 C-36 OTHER CITY/STATE/ZIP NUMBER EXPIRATION DA WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESA REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: [J RESIDENCE ❑ COMMERCIAL IJ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTICTANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG DISTANCE TO NEAREST: WELL ❑ LIFT STATION SIZE TYPE OF PUMP ❑ LEACH LINES LEACHING CHAMBERS CAPACITY CAPACITY ft FOUNDATION ❑ PKG TX PLANT TERNATIVE gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE ft ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) # OF LINES LENGTH OF LINES 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 COMPENSARON LAWS. MI IMUM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED /�ot if re.— TITLE �e CAL) /l 1v Y DATE 6,x7 Application Accepted Final Inspection By,/ Character of Soil top COMMENTS `4P DateArea V("-- Employee ID# Date ❑ SPE IAL PERMIT - Approved by Ft: Pit/Sumo Soil Character: ft ft ft ft ft ft ft ft ft ft ft ft PE DISTANCE TO NEAREST WELL Amount Remitted ft FOUNDATION Invoice # 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 ft 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 COMPENSARON LAWS. MI IMUM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED /�ot if re.— TITLE �e CAL) /l 1v Y DATE 6,x7 Application Accepted Final Inspection By,/ Character of Soil top COMMENTS `4P DateArea V("-- Employee ID# Date ❑ SPE IAL PERMIT - Approved by Ft: Pit/Sumo Soil Character: ft ft ft ft ft ft ft ft ft ft ft ft PE SC INFO Received Check_ #/ B Cas Amount Remitted Date Permit/ Service Request # Invoice # Permit ID# a 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17