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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JO AOUIN CO'4INTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 1. JOB ADDRESS CROSS STREET OWNER NAME OWNER ADDRESS CONTRACTOR CONTRACTOR ADDRESS -7697 FOR INSPECTIONS tXPIRES I YEAR FROM DATE 155UFI 2,Id 11 ccITYY/ IP " (-A , Z-" .\ /�11 APN V GS Q i o 20 ( PARCEL SIZE 11 • /' ,,``��P'HONEI�A-/ I da2'- `r 968 CITY/STATE/ZIP Lod I1 ;-- A l S�LL-t 0 PHONE CITY/STATE/ZIP LICENSE ❑ C-42 ❑r2C-36 OTHER NUMBER _EXPIRATION DATE_ WATER TABLE DEPTH: -j i It GEOGRAPHICAL INFORMATION: Coordinates X _ Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: V NEW INSTALLATION 1 REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE r-1 REPLACEMENT L1 OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: PeRESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: ) NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG P CAPACITY "V gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY—_ gal # OF COMPARTMENTS WELL '113 a)( ft DISTANCE TO NEAREST: WELL 1(�G 1� ft FOUNDATION I �fl PROPERTY LINE 50 y ft ❑ LIFT STATION SIZE TYPE OF PUMP----- - ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) 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. - PLEASE CALL (209) 953-7697. DEPARTMENT USE ONLY Application Accepted By A J A�_ Date ` AreaLL Employee ID# P Y Final Inspection B Date /� �B ❑ SPECIAL PERMIT - Approved by Character of Soil to D h o Pit/Sump Soil Character: — COMMENTS PE Code LEACH LINES XLEACHING CHAMBERS # OF LINES LENGTH OF LINES ;^ 7 , ft Date Permit/ Invoice # Service Request # DISTANCE TO NEAREST WELL '113 a)( ft FOUNDATION —10 ft PROPERTY LINE J+U X ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE To NEAREST WELL ft FOUNDATION ft J 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 t 1ftq FOUNDATION ' ft PROPERTY LINE ft �► SEEPAGE PITS NUMBER WIDTH �1 O• 'If DEPTH S ft DISTANCE TO NEAREST WELL , S L3X ft FOUNDATION _ j 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 WORKERS COMPENSATION LAWS. - PLEASE CALL (209) 953-7697. DEPARTMENT USE ONLY Application Accepted By A J A�_ Date ` AreaLL Employee ID# P Y Final Inspection B Date /� �B ❑ SPECIAL PERMIT - Approved by Character of Soil to D h o Pit/Sump Soil Character: — COMMENTS PE Code SC INFO Received C #/ Cas Amount Remitted Date Permit/ Invoice # Service Request # Permit ID# 4-ki ) :5�E Sg't _121 W161S 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 r