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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT 0-311) CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS c I l % [ �y 4 CITY/ZIP CROSS STREET Q APN VIU 2Zy U PARCEL SIZE (/ /- OWNERNAME CA)i/5 PHONE �%'Y/ OWNER ADDRESS -137 J X, . ix';"-eA- CITY/STATE/ZIP _ It LENGTH ft DEPTH` ® � - ft WELL ra CONTRACTOR _!/ �LZ�/ /� J-e.�fAAf;A/'45:y'e PHONE �L j CONTRACTOR ADDRESSr�- ft CITY/STATE/ZIP WELL LICENSE I I C-42 I J C-36 OTHER / NUMBER EXPIRATION DATE WATER TABLE DEPTH: �� " ft GEOGRAPHICAL INFORMATION: Coordinates X Y Ll PERC TEST # BUILDING PERMIT # CS if "I 2S f I LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: 4-S—RESIDENCE ❑ COMMERCIAL L OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: --3 NUMBER OF EMPLOYEES: V, SEPTIC TANK TYPE/MFG ❑ GREASE TRAP TYPE/MFG ❑ LIFT STATION El DISTANCE TO NEAREST: WELL "41 ft SIZE TYPE OF PUMP LEACHING CHAMBER DISTANCE TO NEAREST WIDTH DISTANCE TO NEAREST WIDTH DISTANCE TO NEAREST WIDTH DISTANCE TO NEAREST CAPACITY iLL/'LI gal # OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS _ FOUNDATION ft PROPERTY LINE t ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) S LEACH LINES ❑ FILTER BED ❑ MOUNDED ❑ SUMPS El DISTANCE TO NEAREST: WELL "41 ft SIZE TYPE OF PUMP LEACHING CHAMBER DISTANCE TO NEAREST WIDTH DISTANCE TO NEAREST WIDTH DISTANCE TO NEAREST WIDTH DISTANCE TO NEAREST CAPACITY iLL/'LI gal # OF COMPARTMENTS CAPACITY gal # OF COMPARTMENTS _ FOUNDATION ft PROPERTY LINE t ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) S SC INFO # OF LINES LENGTH OF LINES ft WELL AIP� ft FOUNDATION _� ft PROPERTY LINE ft ft LENGTH z I ft DEPTH ft WELL ft FOUNDATION ft PROPAYMET ft _ It LENGTH ft DEPTH` ® � - ft WELL It FOUNDATION ft PROPERTY LINE ft It LENGTH ft DEPTH C. R 2 4 MR ft WELL ft FOUNDATION ft PROPERTY LINE ft DISPOSAL PONDS WIDTH ft LENGTH ft DEPTI-PAN JOAQUIN COUNTY ft ENVIRONMEN IAL DISTANCE TO NEAREST WELL ,ft FOUNDATION ft __ ��YI / hAENT ft SEEPAGE PITS NUMBER :z WIDTH WIDTH SGS ft DEPTH i�. j ft DISTANCE TO NEAREST WELL::�Vr-ft FOUNDATION ft PROPERTY LINE 74 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 COMPENSAIION LAWS. MINP06M 1PHOUR ADV CE 4ACE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 9 3-7697 SIGNED - TITLE //Q DATE Application Accepted Final Inspection By Character of Soil 4 COMMENTS DEPARTMENT USE ONLY W Date < �/�/ Area Employee ID# I wit, Date /0 ❑ SPECIAL PERMIT - Approved by )th 4 3 t: f1l Pit/Sump Soil Character: PE SC INFO Received B Check#/ Cash Amount Remitted Date Permit/Code Service Request # Invoice # Permit ID# z I I► 5 A -I 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17