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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 209 953-7697FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZIP CROSS STREET APN PARCEL SIZE p O OWNER NAME PHONE OWNER ADDRESS CITY/STATEIZIP CONTRACTOR PHONE CONTRACTOR ADDRESS CRY/STATE/ZlP LICENSE 'C-42 1-1 C-36 OTHER NUMBER EXPIRATION DATE WATER TABLE DEPTH: it GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # F BUILDING PERMIT# LAND USE APPLICATION# TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION i ENGINEER DESIGNED/ALTERNATIVE REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM I., DESTRUCTION INSTALLATION WILL SERVE: I I RESIDENCE I COMMERCIAL Fl 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 It OF COMPARTMENTS DISTANCE TO NEAREST: WELL it FOUNDATION it PROPERTY LINE it ❑ LIFT STATION SIZE _TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) ❑ LEACH LINES t, LEACHING CHAMBERS #OF LINES LENGTH OF LINES tt DISTANCE TO NEAREST WELL it FOUNDATION fl PROPERTY LINE It ❑ FILTER BED WIDTH It LENGTH it DEPTH ft DISTANCE TO NEAREST WELL It FOUNDATION it PROPERTY LINE I1 ❑ MOUNDED WIDTH It LENGTH it DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION it PROPERTY LINE h ❑ SUMPS WIDTH It LENGTH ft DEPTH it DISTANCE TO NEAREST WELL It FOUNDATION It PROPERTY LINE it ❑ DISPOSAL PONDS WIDTH it LENGTH ft DEPTH It DISTANCE TO NEAREST WELL It FOUNDATION ft PROPERTY LINE ft ❑ SEEPAGE PITS NUMBER WIDTH it DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION It 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED TITLE DATE D P E DEPARTMENT USE ONLY Application Accepted B Date Area Employee ID# Final Inspection By Date ❑ SPECIAL PERMIT-Approved by Character of Soil to Depth of 3 Ft: Pi ump Soil Character: COMMENTS PE SC Received Check#/ Amount Date Permit! Invoice# Permit ID# Code INFO By Cash Remitted Service Request# 3�0�3 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT 5/5/17