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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAM JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 NON-REFUNDABLE PERMIT 14 CALL 209 953-7697 FOR INSPECTIONS PXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 11� CITY/ZIP CROSS STREETl-11 APN 0 'R511 0 PARCEL SIZE 0 �"" PHONE L/��/J / �� OWNER NAME "T1 OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR lel6h-AiePHONE ZI4 2 '> 7— CONTRACTOR CONTRACTOR ADDRESS �/ CITY/STATE/ZIP ea— LICENSE a LICENSE C-42 I J 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/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: LJ RESIDENCE i 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 LEACHING CHAMBERSyy��jj #OF LINES LENGTH OF LINES ft DISTANCE TO NEAREST WELL ft FOUNDATION-/:4- ft PROPERTY LINE/— ft ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft SUMPS WIDTH 112— ft LENGTH � � ft DEPTH ft DISTANCE TO NEAREST WELL 17; 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 It 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. MINIMUMOHOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209)953-7697 SIGNED TITLE DATE r L d / N O Q ON AL M M N D PARTMENTUSE NLY Application AcceptedTV 1 By Date Area Employee ID# csNl� Final Inspection By Date 3 ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth of Ft: Pit/Sump Soil Character: COMMENTS —6!) k ,e PE SC Received eck# Amount Date Permit/ Invoice# Permit ID# Code INFO B Cash Remitted Service Request# 42-01 ONSITE E WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17