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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 ,NON-REFUNDABLE PERMIT CALL 209 953-?697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE(ISSUED JOB ADDRESS tl V CITY/ZIP ! � r 711CROSS STREET PARCEL SIZE N ��/. ! '�! y " / D C - � O OWNER NAME / 1% `� PHONE OWNER ADDRESS C CITY/STATE/ZIP CONTRACTOR PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE I I IC-42 I I I 'C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y i PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNATIV REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: I I RESIDENCE II COMMERCIAL OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE It ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES I I LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ❑ SUMPS WIDTH It LENGTH ft DEPTH IA DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH �JOA,,,.. ft DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LI N�IF/�i,'QOA/44P-A N]fV [AdL3 SEEPAGE PITS NUMBER WIDTH ft DEPTH — p'gRZ4 ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE rft 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 48 I/ VANCE N ICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE DATE .D PARTMENT U E ONLY Application Accepted B Date Area Employee ID#� Final Inspection By Date SZ i I I SPEC AL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Sofl Character: COMMENTS , �) us tp-4 PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# Code INFO B a Remitted Service Request# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17