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` ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SANIJOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-KEFUP JOB ADDRESS CROSS STREET CITY/ZIP L (j� Y3 i APN �/A ` O J PARCEL SIZE OWNER NAME(5/enc��v�s�r PHONE OWNER ADDRESS O v d9CITY/STATE/ZIP CONTRACTOR/l/2, C% G PHONE y�� CONTRACTOR ADDRESSN 6'( i CITY/STATE/ZIP/V1",6, LICENSE I_I IC -42 ❑ I IC -36 OTHER `� ^� / NUMBER l M/� S EXPIRATION DATE :�_ WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: 1 NEW INSTALLATION I I REPAIR/ADDITION I ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT I OUT -OF -SERVICE SEPTIC SYSTEM er0 DESTRUCTION INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: SEPTIC TANK ❑ GREASE TRAP ❑ LIFT STATION TYPE/MFG TYPE/MFG DISTANCE TO NEAREST: WELL SIZE TYPE OF PUMP CAPACITY CAPACITY ft FOUNDATION ❑ PKG TX PLANT ❑ LEACH LINES I I LEACHING CHAMBERS ft PROPERTY LINE ft # OF LINES ft DISTANCE TO NEAREST WELL ft DEPTH ft FOUNDATION ❑ FILTER BED WIDTH ft LENGTH ft ft DEPTH HEALT NMEty—" ft DISTANCE TO NEAREST WELL ft PROPERTY LINE ft FOUNDATION ❑ MOUNDED WIDTH ft LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION ❑ SUMPS WIDTH ft LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION ❑ DISPOSAL PONDS WIDTH ft LENGTH DISTANCE TO NEAREST WELL ft FOUNDATION ❑ SEEPAGE PITS NUMBER WIDTH DISTANCE To NEAREST WELL ft FOUNDATION gal # OF COMPARTMENTS gal # OF COMPARTMENTS ft PROPERTY LINE It ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) LENGTH OF LINES ft ft PROPERTY LINE ft ft DEPTH PAVAi, ft ft PROPERTY LIN ft ft DEPTH ft ft PROPERTY LI ft ft DEPTH 18 ft AN ft PROPERTY �t AQU/ ft ft DEPTH HEALT NMEty—" ft TMFhT ft PROPERTY LINE ft ft DEPTH ft ft PROPERTY LINE ft 1 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 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS 9- PLEASE CALL (209)/953-7697 SIGNED L TITLE DATE c IDE Application Accepted 5y�(`� Final Inspection By 0A4zwLt �uL Character of Soil to Depth of 3 Ft: COMMENTS Zr-775r_ 1 06 W Date Date Pit/Su Area Employee ID#� ❑ SPECIAL PERMIT - Approved by Soil Character: PE SC Received Cqqtck# Amount Date Permit/ Invoice # Permit ID# Code INFO Remitted Service Request # 2 2.- ZED 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17 C z