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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT %6 SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-HIEFUNDABLEEJPERMIT GALL 709 9V-7597 FOR I SPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS %CIT^Y�R�IP (//��[ d �� CROSS STREET , APN�/7— !/ L / PARCEL SIZE i v OWNER NAME�6/9 6i I% i PHONE V —4531*-;- OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR '4>( 2i PHONE L V CONTRACTOR ADDRESS/L�� CITY/STATE/ZIPl C�/- C s/� r �J✓� LICENSE 1 C-42 I_I. C-36 OTHER NUMBER r ��r EXPIRATION DATE WATER TABLE DEPTH: KYZV ft GEOGRAPHICAL INFORMATION: Coordinates X Y 7 PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: SIDENCE D COMMERCIA L 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 ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) C LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH F LINES ft DISTANCE TO NEAREST WELL 41(- FOUNDATION ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ 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 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. SIGNED Application Accepted By Final Inspection By Character of Soil to D pt COMMENTS 190 e of 3 Ft: ' Date Date TITLE Area CI SPE Pit/Sump Soil Character: P DATE Employee ID# - Approved by PE Sc Received heck Amount Permit/ Code INF BQQ ash emitted Date Invoice # Permit ID# // w ly' �Se9r�v�ic-e7Request //# SQ6 / S IO 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17