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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 # OF LINES -3 LENGTH OF LINES ft CALL�r�209 953-7697FORINSP C NS EXPIRES 1 YEAR FROM DATE ISSUEI JOB ADDRESS (7 Y,r� 4 V CITY/ZIP I f P AL h 6 Cn eo d p CROSS STREET Sneed FOUNDATION ft PROPERTY LIN a ft ❑ SUMPS WIDTH ft LENGTH APN 3 2 6 PARCEL SIZE S OWNER NAME ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH SAID fn�fjj4ft Ar'� /VO� Q PHON 5 V iIWNER ADDRESS /✓ ❑ SEEPAGE PITS NUMBER WIDTH �%I^ v � CITY/STATE/ZIP / G!% S ✓ �/� CONTRACTOR I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN PHONE CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL CONTRACTOR ADDRESS CITY/STATE/ZIP MINIMUM O AD ANCE NOTICE REQUIRED LICENSE I I C-42 11 C-36 OTHER TITLE %�iU%%C ems/ . Y DATE NUMBER EXPIRATION DATE II w — I 10 WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: NEW INSTALLATION R PAIR/ADDITION ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT -OF -SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: NeIRESIDENCE I I COMMERCIAL�j ❑ OTHER NUMBER OF LIVING UNITS: I NUMBER OF BEDROOMS: ✓ NUMBER OF EMPLOYEES: SEPTIC TANK TYPE/MFG 1 � L" CAPACITY 2 DC)gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL 00Ir ft FOUNDATION 2 (J ft PROPERTY LINE I& & ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) 1" LEACH LINES LEACHING CHAMBERS # OF LINES -3 LENGTH OF LINES ft vv DISTANCE TO NEAREST WELL I Old '1 ft FOUNDATION 604 ft PROPERTY LINE ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH 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 LIN a ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE A ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH SAID fn�fjj4ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPE INE �0 ft AQU/ ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH E .�I ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROP FF� Y 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. MINIMUM O AD ANCE NOTICE REQUIRED FOR INSPECTION - LEASE CALL 209 953-7697 SIGNED 12.1-/l �i) TITLE %�iU%%C ems/ . Y DATE D fiffi A R T M E N E O Application Accepted By CfijE Date_ Area It lqq Employee ID# Final Inspection By-2aliY► DateiC9 J1 II k Cl SPECIAL PERMIT -Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS 5�1*y Cr' -7 PE Code SC INFO Received BCash Check#/ Amount Remitte Date Permit/ Service Request # Invoice # Permit ID# 5/5/17 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 C�'� J �'%7 T Y C C