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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 -j- CITY/ZIP �r�oYI.} T 'A ►+- CROSS STREET APN PARCEL SIZE OWNER NAME wz*VPHONE OWNER ADDRESS?o�!{� / CITY/STATE/ZIP V� CONTRACTOR � LAIC�f � PHONE CONTRACTOR ADDRESS 7'f) �7C J CITY/STATE/ZIP LICENSE ❑, C-42 Ili iC-36 OTHER NUMBER S. EXPIRATION DATE_ WATER TABLE DEPTH:4�t it GEOGRAPHICAL INFORMATION: Coordinates X Y PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGN REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM DESTRUCTION INSTALLATION WILL SERVE: �/f4ESIDENCE _I COMMERCIAL OTHER APP s NUMBER OF LIVING UNITS: ( NUMBER OF BEDROOMS:—? NUMBER OF EMPL S: ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COM IN "It ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF C0MPA�IRT IE I; T; r 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 I I LEACHING CHAMBERS #OF LINES LENGTH OF LINES �:� I ft DISTANCE TO NEAREST WELL 11 JA ft FOUNDATION 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 LINE it ❑ 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 WeeSEEPAGE PITS NUMBER -11 WIDTH ft DEPTH �.s I ft DISTANCE TO NEAREST WELL A /A ft FOUNDATION loft 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. MINIMUM 48 HQUU ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL 209 953-7697 SIGNED TITLE �11 j&:!44G1' DATE in wE L26 EPARTMENT SE N Y Application Accepted B Date- &-410/ �-'I Area 'C Employee ID# Final Inspection By Date L I I SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: COMMENTS PE SC Received Amount Permit/Code INFO B Cash emitted Date Service Request# Invoice# Permit ID# 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17