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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN'OAQURJ COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON -REFUND LE PERMIT GALL ZU9 953-7 -97 FOR INSPECTIONS tXPIRES 1 YEAR FROM DATE ISSUEI JOB ADDRESS ( /- CITY/ZIP L 3 CROSS STREET (co ,/� APN'2% O ®7 y0 % 1 PARCEL SIZE (�1-5;—/ ft DEPTH DISTANCE TO NEAREST: WELL ft FOUNDATION `S� ft PROPERTY LINE ft OWNER NAME v r /if'{ Y 114IMy PHONE OWNER ADDRI TE/ZIP CONTRACTOR AA49/4 `tt/'r4i^L V`CWQ^ PHONE CONTRACTOR ADDRESS / / 4 ��V �� {/� CITY/STATE21P ' " �y. �• / �.��_ LICENSE [IDC -42 ❑i C-36 OTHER A- NUMBER�.j EXPIRATION DATE �zJj-/ ►^ WATER TABLE DEPTH: D I !ti ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE k REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION�/�1� INSTALLATION WILL SERVE: 0 RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: Z NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG >/z NG` CAPACITY gal # OF COMPARTMENTS 2-1 ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS ft DEPTH 11 �dc/ , f ❑ SUMPS WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST: WELL ft FOUNDATION `S� ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES '0I LEACHING CHAMBERS # OF LINES LENGTH OF LINES DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE lJ FILTER BED WIDTH t'7 ft LENGTH `7 O ft DEPTH DISTANCE TO NEAREST WELL/06 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 COMPENSATION LAWS. SIGNED Application Accepted By"ff Final Inspection By Character of Soil to Depth of 3 Ft: COMMENTS ! �T FOR INSPECTIONS - PLEASE CALL (209) 953-7697 TITLE �rPyC©/ DATE 101 .. DEPARTMENT USE ON V Date Area Employee ID# Date 7 / ❑ S#CIAL PEMIT - Approved by Pit/Sump Soil Character: 7 f o nA-rib2�n1 ft ft ft ft ft ft ft ft ft ft ft ft PE Code SC INFO Receivedheck#/ Cash Amount emitte Date Permit/ Service Request # Invoice # Permit ID# =6 I Lk I Z� -1A -� 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17