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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 IMUN-REFUNDAB LE ERMITLA ZU`9 .95.3-115'9/ FOR INSPECTIONS tXPIRES 1 YEAR FROM DATE ISSUE JOB ADDRESS CITY/ZIP CROSS STREET / �S47 A.PN X150 /� PARCEL SIZE d. OWNER NAME V� v v�/�/rl PHONE �/ L OWNER ADDRESS d CITY/STATE/ZIP ` CONTRACTOR AA L Of J C/ PHONE --5J / / ��Ir CONTRACTOR ADDRESS C� ADDRESS-CITY/STATE/ZIP LICENSE I , C-42 C-36 OTHER _ NUMBER J � —(-,"J7Y EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # I BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE K REPLACEMENT INSTALLATION WILL SERVE:) RESIDENCE NUMBER OF LIVING UNITS: ® SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION ❑ COMMERCIAL ❑ OTHER NUMBER OF BEDROOMS: �� ^^ NUMBER OF EMPLOYEES: CAPACITY Z_ C� V gal # OF COMPARTMENTS_ CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ SC Received Check#/ Amount LEACH LINES LEACHING CHAMBERS # OF LINES Code LENGTH OF LINES ft B DISTANCE TO NEAREST WELL ft FOUNDATION Service Request # ft PROPERTY LINE ft FILTER BED WIDTH ft LENGTH it DEPTH ��ri �Z ft 000 0 +.�2 DISTANCE TO NEAREST WELL ft FOUNDATION -to ft PROPERTY LINE S It ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft 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 it 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. MINIMUM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLEDATE Application Accepted By 7 Final Inspection By4e Character of Soil to Depth of COMMENTS Date ! S Area `tel 1 Employee ID#� ❑ SPECIAL PERMIT - Approved by Pit/Sump Soil Character: PE SC Received Check#/ Amount Permit/ Code INFO B Cash Remitted Date Service Request # Invoice # Permit ID# I 1-IHg 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17