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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 CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 0- y /1 F1 /./✓ CITY/ZIP +.aL CROSS STREET C'.#1 / �I/h APN _ �� /- � 0 {�� PARCEL SIZE' / 21 OWNER NAME C/" n `-k1-") �+�-d��1�� 1 PHONE # OF LINES LENGTH OF LINES 15— ft OWNER ADDRESS CITY/STATE/ZIP / CONTRACTOR%C, FOUNDATION �-;% PHONE _7 CONTRACTOR ADDRESS yJ ! / �UV : ^ �� CITY/STATE/ZIP FILTER BED LICENSE I C-42 1 C-36 OTHER A NUMBER ol Jls EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL ERVE: ❑ RESIDENCE ❑ COMMERCIAL Ll OTHER NUMBER OF LIVING UNITS: ` NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: _ zD_ ❑ SEPTIC TANK TYPE/MFG` ��//V� CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft LIFT STATION SIZ-E TYPf OF PUMP,�'�J LlPKG TX PLANT ElSAND 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 COMPEN3A LAWS. SIGNED Application Accepted Final Inspection By_ Character of Soil to D COMMENTS J A I 'cn.i / - rL.GN JG {JML.L (GV9/ DATE 2 TMENTJJSE O LV Date / Area Employee ID#� Date Z i / Cl SPECIAL PERMIT - Approved by Pit/Sump Soil C)laracter: —A PE Code SC INFO ' 1 Amount Remitted Z (ZI 0 LEACH LINES LEACHING CHAMBERS 4-151 # OF LINES LENGTH OF LINES 15— ft DISTANCE TO NEAREST WELL ft 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 It FOUNDATION ft PROPERTY LINE ft 'Cl SEEPAGE PITS NUMBER Y WIDTH V . ft DEPTH Z 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 COMPEN3A LAWS. SIGNED Application Accepted Final Inspection By_ Character of Soil to D COMMENTS J A I 'cn.i / - rL.GN JG {JML.L (GV9/ DATE 2 TMENTJJSE O LV Date / Area Employee ID#� Date Z i / Cl SPECIAL PERMIT - Approved by Pit/Sump Soil C)laracter: —A PE Code SC INFO Received B Check#/ Cash Amount Remitted Permit/ Service Request # Invoice # Permit ID# 4-151 1 L4 0 `^ _Date 1Y 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 :j