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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUM COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NUN-REFUNDABL ERMIT 05. CALL 209 953-7697 FOR INSPECTIONS XPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZIP V-4n te 9513 3(a H � ,/�/n) CROSS STREET APN ��' PARCEL SIZE / a �d OWNER NAME PHONC90q ""'qq-�� i OWNER ADDRESS -/, 0 � I✓'a / CITY/STATE21P &,-, CONTRACTOR / C PHON�D /* CONTRACTOR ADDRESS �1 CITY/STATE/ZIP I ( �� a �1 � LICENSE Ll iC-42 IC-36 OTHER NUMBE / EXPIRATION DATE/O 3 / r ,DP ! q WATER TABLE DEPTH: /C- / ft GEOGRAPHICAL INFORMATION: Coordinates X Y 1_I PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: I NEW INSTALLATION I REPAIR/ADDITION 11 ENGINEER DESIGNED/ALTERN TIVE REPLACEMENT I I OUT-OF-SERVICE SEPTIC SYSTEM -)< DESTRUCTION 01 INSTALLATION WILL SERVE: �14ESIDENCE 11 COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: / NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: JR SEPTIC TANK TYPE/MFG '� °� L CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS 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 2-� ft LENGTH 30 ft DEPTH ; 7 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 it ❑ 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 WORKERS COMPENSATION LAWS. !TUM 48 HOVR f&,F NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 G SIGNE �' TITLE ('5n±f 4t �r�Y �il .� DATE 5 6 r I 0 E N H F T I Eli 1. 1 1 1 1 1 1 1 1 TLI DEPARTMENT USE ONLY /I r (e Application Accepted By Date Area. l Employee ID# /� .�•M Final Inspection By Date 31a 9/I 9 ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS SST a,6�'44i 0a� PE SC Received Check#/ Amount Permit/ Code �INFO B Cash Remitted Date Service Request# Invoice# Permit ID# 920 3 �o 42-01 /j ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 / �. s-7 e> �l`�