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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT P V' ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 IYUI4-nt1-L1NUAt3LE rEHMI I ft GEOGRAPHICAL [NFOR ATION: Coordin tes X GALL ZU9 93-7697 FOR INSPECTIONS EXPIRES 1/ FR M DATE ISS E JOB ADDRESS AND USE APPLICATION # / CITY/ZIP— — C C CROSS STREET !,YEAR LF-+ O % APN-t-70-120 PARCEL SIZE � ❑ COMMERCIAL ❑ �1 Lt-iYl NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: _ NUMBER OF EMPLOYEES: OWNER NAME `'�1 r _ PHONE TYPE/MFG CAPACITY gal # OF COMPARTMENTS L DISTANCE TO NEAREST: WELL BOO 'T OWNER ADDRESS • ft PROPERTY LINE ft ❑ LIFT STATION v �Y CITY/STATE/ZIP 052 CONTRACTOR / �1 Y I _ PHONE W-01 ft PROPERTY LINE ft CONTRACTOR ADDRESS SEEPAGE PITS NUMBER —7 WIDTH w to ft O N _ CITY/STATE/ZIP LICENSE I Y42 I I C-36 OTHER NUMBER. O EXPIRATION DATE JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS WATER TABLE DEPTH: ft GEOGRAPHICAL [NFOR ATION: Coordin tes X Y 1 PERC TEST # BUILDING PERMIT # AND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE DEPTH ft REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: _ NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG I".l G /�� CAPACITY _ VV gal # OF COMPARTMENTS 1pt ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS L DISTANCE TO NEAREST: WELL BOO 'T ft FOUNDATION/40 /O • ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) MINIMUM,P4`HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE _ _ rl a r DATE 7--30 ,AJ 78 Application Accepted By Final Inspection By Character of Soil to Depth of 3 COMMENTS Date Y 0/ Area Employee ID# _1'1 ❑ SPECIAL KERMIT - Approved by mp Soil Character: PE Code LEACH LINES LEACHING CHAMBERS # of LINES � 101 LENGTH OF LINES � ft Check#/ Amount Cash Remi d DISTANCE TO NEAREST y i WELL / ®Q ft FOUNDATION f ft PROPERTY LINE POP 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 —7 WIDTH w to ft DEPTH 51.c P ft DISTANCE TO NEAREST WELL ft FOUNDATION 6 ft PROPERTY LINE BOO • 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,P4`HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 SIGNED TITLE _ _ rl a r DATE 7--30 ,AJ 78 Application Accepted By Final Inspection By Character of Soil to Depth of 3 COMMENTS Date Y 0/ Area Employee ID# _1'1 ❑ SPECIAL KERMIT - Approved by mp Soil Character: PE Code SC INFO Received By Check#/ Amount Cash Remi d Date Permit/ Service Request # Invoice # Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 'J.