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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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 4 G � d CITY/ZIP l /f 4 CROSS STREET 7�� oG APN Z11 1 ��O PARCEL SIZE-L` p v OWNER NAME < 42 1 PHONE M OWNER ADDRES f ��'��v S CIT/STATE21P CONTRACTOR I , V r PHONE L)C)2 CONTRACTOR ADDRESS �� i CITY/STATE/ZIP e9,, / LICENSE I I IC-42 I I I IC-36 OTHER NUMBER X EXPIRATION DATE WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y U PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED/ALTERNAT E REPLACEMENT I OUT-OF-SERVICE SEPTIC SYSTEM XXDESTRUCTION '�n('L`��/�p INSTALLATION WILL SERVE: I I RESIDENCE I I COMMERCIAL OTHER NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: t_I�PTIC TANK TYPE/MFG 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 It 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 LINE ft ❑ 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 1 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 41HO TICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLEE�,IJ�'tI .�C /��t DATE uN� o s � Q EPARTMENT SE dNLY Application AccepteAof Date Area IAd Employee ID# Final Inspection By Date 1� SPE IAL PERMIT-Approved by Character of Soil to Pit/Sump Soil Character: COMMENTS r�mK K cL (X /ei o -e co ✓�' - cf S o SP re c Af far✓41 PE SC Received Check#/ Amount Date Permit/ Invoice# Permit ID# Code INFO Bv ash Remitted Service Request# U o 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17