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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 NUN -REFUNDABLE PERMIT GALL Z 53-7(3 FOR INSPECTIONS EXPI%S,.lYM FROM DATE ISSUEI JOB ADDRESS PERC TEST # CITY/ZIP I cuuut-j LAND USE APPLICATION # CROSS STREET D j�n q 1/' �' V G� APND�� ` { O PARCEL SIZE OWNER NAME JAMP-PHONE Remitted Date V OWNER ADDRESS I V 6 f� �Q Gi6--4 J �4 r., CITY/STATE/ZIPy Gam^ v' — R5 z I - 4 �• K5 CONTRACTORD. A M �j�� ''v PHONE -':)6(07 CONTRACTOR ADDRESS ° L �• "' �/ CITY/STATE/ZIP � W5 LICENSE I)(C-42 I I C-36 OTHER NUMBER=5 0 EXPIRATION DATE _V ° ( 1 WATER TABLE DEPTH:'� l� ft GEOGRAPHICAL INFORMATION: Coordinates X Y heck." Amount PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE Remitted Date ° REPLACEMENT/ OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION L INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL 6THER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: I SEPTIC TANK TYPE/MFG01100 — CAPACITY ` gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS�y., 6n � 157o 10 DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ✓ ' ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) ❑ LEACH LINES LEACHING CHAMBERS # OF LINES LENGTH OF LINES 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 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 WORKEACOMPEN glON,LAWS ^ - SIGNED \ X )kJ N---- \./ 1,/ � Aj %J --- ___ TITLE - `"' J DATE Application Accepted By Final Inspection By Character of Soil to Depth of 3 Ft: COMMENTS DEFON6V I Area Employee ID# ❑ SPECIAL PERMIT -Approved by PE SC Received heck." Amount Permit/ Code INFO By Remitted Date Service Request Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 a