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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />_ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIRIADDITION ENGINEER DESIGNED/ALTERNATIVE <br />REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION <br />INSTALLATION WILL SERVE: RESIDENCE I-1 COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: 3 NUMBER OF EMPLOYEES: <br />❑ <br />SEPTIC TANK <br />TYPE/MFG <br />Amount <br />Remitted <br />CAPACITY L1�©: <br />Permit/ <br />Service Request # <br />gal # OF COMPARTMENTS <br />Permit ID# <br />❑ <br />GREASE TRAP <br />TYPE/MFG <br />Q <br />CAPACITY <br />gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: <br />/1� <br />WELL � n It <br />FOUNDATION <br />Z 0 <br />/� <br />It PROPERTY LINE 1001 <br />ft <br />❑ <br />LIFT STATION <br />SIZE TYPE OF PUMP <br />❑ PKG TX PLANT <br />❑ <br />SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />kr <br />LEACH LINES <br />Y LEACHING CHAMBERS <br />4st <br />_ # OF LINES <br />I <br />LENGTH OF LINES �LJ <br />ft <br />W <br />40 <br />1 / <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE X OU <br />ft <br />❑ <br />FILTER BED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />it PROPERTY LINE <br />ft <br />❑ <br />MOUNDED <br />WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />SUMPS <br />WIDTH <br />ft LENGTH <br />It <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ <br />DISPOSAL PONDS WIDTH <br />ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION <br />It PROPERTY LINE <br />ft <br />SEEPAGE PITS <br />NUMBER <br />WITH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST <br />WELL 5 ®{' ft <br />FOUNDATION <br />D <br />ft PROPERTY LINE n+ <br />ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />SIGNED <br />DATE <br />1 J6 <br />y:; f !, <br />1.9 <br />D ARTMEN E ON L Y a,I <br />Application Accepted ByAIMADate C5 Area E� <br />Final Inspection By Date1 11 SPE IAL PERMIT - Approve V <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />COMMENTS se... ON <br />EN �WUIN Co, <br />TH DENTAC <br />'rA <br />PE <br />Code <br />SC <br />INFO <br />Receiv <br />B Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Permit ID# <br />(v Irk$ <br />Q <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />5/5/17 <br />T <br />